Cecal volvulus - a rare cause of acute abdomen with ileus.

In this article, we present case reports of two patients admitted to the University Hospital in Pilsen for acute abdomen due to a disorder of the passage through the gastrointestinal tract (GIT). Both were indicated for surgery. The patients were diagnosed intraoperatively with rarely occurring cecal volvulus (CV). The findings required an ileocecal resection; nevertheless, both patients fully recovered despite the need the resection.

Preoperative electroacupuncture versus sham electroacupuncture for the treatment of postoperative ileus after laparoscopic surgery for colorectal cancer in China: a study protocol for a multicentre, randomised, sham-controlled trial.

INTRODUCTION: Postoperative ileus (POI) is a postoperative complication that can cause lingering recovery after colorectal resection and a heavy healthcare system burden. Acupuncture aims to prevent postoperative complications, reduce the duration of POI, help recovery and shorten hospital stays. We hypothesise that preoperative electroacupuncture (EA) can promote POI recovery under the enhanced recovery after surgery protocol after laparoscopic surgery in patients with POI. METHODS AND ANALYSIS: This is a multicentre, randomised, sham-controlled trial. A total of 80 patients will be enrolled and randomly assigned to the EA or sham electroacupuncture (SA) group. The eligible patients will receive EA or SA for one session per day with treatment frequency starting on preoperative day 1 for four consecutive days. The primary outcome is the time to first defecation. The secondary outcomes include the time to first flatus, length of postoperative hospital stay, time to tolerability of semiliquid and solid food, postoperative nausea, vomiting, pain and extent of abdominal distention, time to first ambulation, preoperative anxiety, 30-day readmission rate, the usage of anaesthetics and analgesics during operation, length of postanaesthesia care unit stay. A mechanistic study by single-cell RNA sequencing in which postintervention normal intestinal tissue samples will be collected. The results of this study will provide evidence of the effects of acupuncture on POI and promote good clinical decision to millions of patients globally every year. ETHICS AND DISSEMINATION: This study has been approved by the ethical application of Beijing University of Chinese Medicine (2022BZYLL0401), Beijing Friendship Hospital Affiliated to Capital Medical University(2022-P2-368-02), Cancer Hospital Chinese Academy of Medical Science (23/175-3917), Huanxing Cancer Hospital (2023-002-02). The results will be published in a medical journal. In addition, we plan to present them at scientific conferences. TRIAL REGISTRATION NUMBER: ChiCTR2300077633.

Comparison of low versus high (standard) intraabdominal pressure during laparoscopic colorectal surgery: systematic review and meta-analysis.

BACKGROUND: To evaluate outcomes of low with high intraabdominal pressure during laparoscopic colorectal resection surgery. METHODS: A systematic search of multiple electronic data sources was conducted, and all studies comparing low with high (standard) intraabdominal pressures were included. Our primary outcomes were post-operative ileus occurrence and return of bowel movement/flatus. The evaluated secondary outcomes included: total operative time, post-operative haemorrhage, anastomotic leak, pneumonia, surgical site infection, overall post-operative complications (categorised by Clavien-Dindo grading), and length of hospital stay. Revman 5.4 was used for data analysis. RESULTS: Six randomised controlled trials (RCTs) and one observational study with a total of 771 patients (370 surgery at low intraabdominal pressure and 401 at high pressures) were included. There was no statistically significant difference in all the measured outcomes; post-operative ileus [OR 0.80; CI (0.42, 1.52), P = 0.50], time-to-pass flatus [OR -4.31; CI (-12.12, 3.50), P = 0.28], total operative time [OR 0.40; CI (-10.19, 11.00), P = 0.94], post-operative haemorrhage [OR 1.51; CI (0.41, 5.58, P = 0.53], anastomotic leak [OR 1.14; CI (0.26, 4.91), P = 0.86], pneumonia [OR 1.15; CI (0.22, 6.09), P = 0.87], SSI [OR 0.69; CI (0.19, 2.47), P = 0.57], overall post-operative complications [OR 0.82; CI (0.52, 1.30), P = 0.40], Clavien-Dindo grade ≥ 3 [OR 1.27; CI (0.59, 2.77), P = 0.54], and length of hospital stay [OR -0.68; CI (-1.61, 0.24), P = 0.15]. CONCLUSION: Low intraabdominal pressure is safe and feasible approach to laparoscopic colorectal resection surgery with non-inferior outcomes to standard or high pressures. More robust and well-powered RCTs are needed to consolidate the potential benefits of low over high pressure intra-abdominal surgery.

Testing Machine Learning Models to Predict Postoperative Ileus after Colorectal Surgery.

Background: Postoperative ileus (POI) is a common complication after colorectal surgery, leading to increased hospital stay and costs. This study aimed to explore patient comorbidities that contribute to the development of POI in the colorectal surgical population and compare machine learning (ML) model accuracy to existing risk instruments. Study Design: In a retrospective study, data were collected on 316 adult patients who underwent colorectal surgery from January 2020 to December 2021. The study excluded patients undergoing multi-visceral resections, re-operations, or combined primary and metastatic resections. Patients lacking follow-up within 90 days after surgery were also excluded. Eight different ML models were trained and cross-validated using 29 patient comorbidities and four comorbidity risk indices (ASA Status, NSQIP, CCI, and ECI). Results: The study found that 6.33% of patients experienced POI. Age, BMI, gender, kidney disease, anemia, arrhythmia, rheumatoid arthritis, and NSQIP score were identified as significant predictors of POI. The ML models with the greatest accuracy were AdaBoost tuned with grid search (94.2%) and XG Boost tuned with grid search (85.2%). Conclusions: This study suggests that ML models can predict the risk of POI with high accuracy and may offer a new frontier in early detection and intervention for postoperative outcome optimization. ML models can greatly improve the prediction and prevention of POI in colorectal surgery patients, which can lead to improved patient outcomes and reduced healthcare costs. Further research is required to validate and assess the replicability of these results.

An outline of the management and prevention of postoperative ileus: A review.

Postoperative ileus (POI) is a prevalent surgical complication, which results in prolonged hospitalization, patient distress, and substantial economic burden. The literature aims to present a brief outline of interventions for preventing and treating POI post-surgery. Data from 2014 to 2023 were gathered from reputable sources like PubMed, PubMed Central, Google Scholar, Research Gate, and Science Direct. Inclusion criteria focused on studies exploring innovative treatments and prevention strategies for POI, using keywords such as novel POI treatments, non-pharmacological prevention, POI incidence rates, POI management, and risk factors. The findings revealed that integration of preventive measures such as coffee consumption, chewing gum, probiotics, and use of dikenchuto within enhanced recovery programs has significantly reduced both the frequency and duration of POI, without any adverse effects, with minimally invasive surgical approaches showing promise as an additional preventive strategy. While treatment options such as alvimopan, NSAIDs, and acupuncture have demonstrated efficacy, the use of lidocaine has raised concerns due to associated adverse effects. The ongoing exploration of novel therapeutic strategies such as targeting the mast cells, vagal nerve stimulation and tight junction protein, and prokinetic-mediated instigation of the cholinergic anti-inflammatory trail not only holds promise for enhanced treatment but also deepens the understanding of intricate cellular and molecular pathways underlying POI. POI presents a complex challenge in various surgical specialties, necessitating a multifaceted management approach. The integration of preventive and treatment measures within enhanced recovery programs has significantly reduced POI frequency and duration.

Bouveret Syndrome: A Curious Simultaneous Presentation of Two Cases: Comparison of Clinical Observations and Surgical Management.

Gallstone ileus is an uncommon occurrence and accounts for about 0.3-0.5% of complications of cholelithiasis in elderly patients. Bouveret syndrome is an uncommon medical condition resulting from the blockage of the duodenal bulb by a stone, which consequently obstructs the outlet of the stomach. Until now, a comparison of two different presentations of Bouveret syndrome has not been published in the literature due to the rarity of this pathology. The curious simultaneous occurrence of the two cases discussed here made it possible for us to compare the different diagnostic and therapeutic pathways. In fact, both cases differ not only in their presenting symptoms, but also in the management adopted by the same surgical team.

Enhanced recovery programs following adhesive small bowel obstruction surgery are feasible and reduce the rate of postoperative ileus: a preliminary study.

PURPOSE: The recovery of gastrointestinal function and postoperative ileus are the leading goals for clinicians following surgery for adhesive small bowel obstruction. While enhanced recovery programs may improve recovery, their feasibility in emergency surgery has not yet been proven. We sought to assess the incidence of postoperative ileus in patients following surgery for ASBO and the feasibility of enhanced recovery programs, including their benefits in the recovery of gastrointestinal functions and reducing the length of hospitalization. METHODS: This prospective study includes the first 50 patients surgically treated for ASBO between June 2021 and November 2022. Their surgery was performed either as an emergency procedure or after a short course of medical treatment. The main aim was to compare the observed rate of postoperative ileus with a theoretical rate, set at 40%. The study protocol was registered in clinicaltrials.gov under the number NCT04929275. RESULTS: Among the 50 patients included in this study, it reported postoperative ileus in 16%, which is significantly lower than the hypothetical rate of 40% (p = 0.0004). The median compliance with enhanced recovery programs was 75% (95%CI: 70.1-79.9). The lowest item observed was the TAP block (26%) and the highest observed items were preoperative counselling and compliance with analgesic protocols (100%). The overall morbidity was 26.5%, but severe morbidity (Dindo-Clavien > 3) was observed in only 3 patients (6%). Severe morbidity was not related with the ERP. CONCLUSION: Enhanced recovery programs are feasible and safe in adhesive small bowel obstruction surgery patients and could improve the recovery of gastrointestinal functions. CLINICAL TRIAL REGISTRY: NCT04929275. WHAT DOES THE STUDY CONTRIBUTE TO THE FIELD?: Perioperative management of adhesive small bowel obstruction (ASBO) surgery needs to be improved in order to reduce morbidity. Enhanced recovery programs (ERP) are both feasible and safe following urgent surgery for ASBO. ERPs may improve the recovery of gastrointestinal (GI) functions.

[Small bowel obstruction with an unusual background]. / Egy szokatlan hátteru vékonybél ileus.

Bevezetés: Kompressziós vékonybél ileus esetét ismertetjük, amelyet a bélfodor nem gyakori, inflammatorikus természetu betegsége, mesenterialis panniculitis idézett elo. A magyar szakirodalomban ilyen közléssel nem találkoztunk. Esetismertetés: A 91 éves férfi akut hasi panaszokkal került kórházba. A vizsgálatokkal vékonybél ileus derült ki. Ennek hátterében mutétkor malignitásra gyanús, bélfodri multinodularis elváltozást fedtünk föl. A biopsziából mesenterialis panniculitist diagnosztizáltunk. A ritka, több nyitott kérdéssel terhelt entitást mutatjuk be az irodalom és a saját észleleteink tükrében. Következtetések: Számos differenciáldiagnosztikai eshetoség figyelembevételével a kórkép szövettanilag igazolható. A diagnózis felállítása után a további teendoket az egyéb leletek és az adott klinikai kontextus gondos elemzése fogja meghatározni.

The "Tumbling Gallstone Sign" of Obstructive Gallstone Ileus.

The "tumbling gallstone sign" is a diagnostic imaging finding described on radiologic examinations of the abdomen, in patients with cholelithiasis associated with intermittent episodes of gallstone obstructive ileus.  Best seen on serial radiographs or CT studies of the abdomen, this sign indicates a sudden change in position of the gallstone(s) within the intestinal lumen from the upper segments of the bowel to the lower segments of the bowel, causing transient mechanical bowel obstruction.  The tumbling gallstone sign has been likened to that of the classic childrens' tumbling tower balancing game.  On repeat CT scans, the dislodged gallstone(s) may be seen proceeding distally and impact in the ileum at a level lower than that seen on the previous CT scans, analogous to the tumbling gallstone sign.

Docosahexaenoic acid (DHA) promotes recovery from postoperative ileus and the repair of the injured intestinal barrier through mast cell-nerve crosstalk.

The objective of this study was to investigate the neuroimmune mechanisms implicated in the enhancement of gastrointestinal function through the administration of oral DHA. Mast cell-deficient mice (KitW-sh) and C57BL/6 mice were used to establish postoperative ileus (POI) models. To further validate our findings, we conducted noncontact coculture experiments involving dorsal root ganglion (DRG) cells, bone marrow-derived mast cells (BMMCs) and T84 cells. Furthermore, the results obtained from investigations conducted on animals and cells were subsequently validated through clinical trials. The administration of oral DHA had ameliorative effects on intestinal barrier injury and postoperative ileus. In a mechanistic manner, the anti-inflammatory effect of DHA was achieved through the activation of transient receptor potential ankyrin 1 (TRPA1) on DRG cells, resulting in the stabilization of mast cells and increasing interleukin 10 (IL-10) secretion in mast cells. Furthermore, the activation of the pro-repair WNT1-inducible signaling protein 1 (WISP-1) signaling pathways by mast cell-derived IL-10 resulted in an enhancement of the intestinal barrier integrity. The current study demonstrated that the neuroimmune interaction between mast cells and nerves played a crucial role in the process of oral DHA improving the intestinal barrier integrity of POI, which further triggered the activation of CREB/WISP-1 signaling in intestinal mucosal cells.

Comparison of the Kron technique and digital manometry for measuring intra-abdominal pressure in emergency department patients diagnosed with ileus.

BACKGROUND: Numerous measurement techniques for intra-abdominal pressure have been explored, with the Kron Technique established as the gold standard. Despite its prominence, the search for alternative methods persists due to its lengthy application time, the requirement for additional equipment, and overall impracticality. This study investigated a quicker, more accessible method for effective intra-abdominal pressure measurement in the emergency department. It aimed to compare intra-abdominal pressure measurements in patients diagnosed with ileus using a digital manometer and the Kron Technique. METHODS: Conducted from October 2022 to February 2023, this single-center, prospective, single-blind method comparison study involved patients diagnosed with ileus at a tertiary emergency department. Intra-abdominal pressure was measured using both the Kron Technique and a digital manometer by separate practitioners blinded to the study results. RESULTS: The study included 30 patients. No statistically significant difference was observed in the intra-abdominal pressure measurements between the two methods (p<0.237). A very strong correlation existed between the two methods (Spearman's Rho = 0.998). Bland-Altman analysis showed a bias value of 0.091 mmHg for the digital manometer, with upper and lower agreement limits of -0.825 and 1.007 mmHg, respectively. The measurement time was significantly shorter with the digital manometer than with the Kron Technique (15 vs. 390.5 seconds; p<0.001). CONCLUSION: We believe that the intra-abdominal pressure measurement technique using a digital manometer is a method that can be effectively employed by healthcare professionals in emergency departments. This technique offers ease of use, requires minimal equipment, provides rapid results, and delivers reliable measurement values compared to the Kron Technique.

Short-term outcome of intracorporeal ileocolonic anastomosis in patients with visceral obesity.

The primary objective of this study was to compare short-term outcomes between Intracorporeal ileocolic anastomosis (IIA) and extracorporeal ileocolic anastomosis (EIA) after laparoscopic right hemicolectomy in patients with visceral obesity. The secondary objective was to identify risk factors associated with prolonged postoperative ileus (PPOI) after laparoscopic right hemicolectomy. This single-center retrospective study analyzed visceral obesity patients who underwent laparoscopic right hemicolectomy for primary bowel cancer between January 2020 and June 2023. Patients were categorized into IIA and EIA groups based on the type of anastomosis, and a 1:1 propensity score-matched analysis was performed. A total of 129 patients were initially included in this study, with 45 patients in each group following propensity score matching. The IIA group had significantly longer anastomosis times (p < 0.001), shorter incision length (p < 0.001), and shorter length of stay (p = 0.003) than the EIA group. Meanwhile, the IIA group showed a shorter time to first flatus (p = 0.044) and quicker tolerance of a solid diet (p = 0.030). On multivariate analysis, postoperative use of opioid analgesics is an independent risk factor for PPOI (OR: 3.590 95% CI 1.033-12.477, p = 0.044), while IIA is an independent protective factor (OR: 0.195 95% CI 0.045-0.843, p = 0.029). IIA remains a safe and feasible option for visceral obesity patients. It is also associated with a quicker recovery of bowel function and shorter length of stay when compared to EIA. Additionally, IIA is an independent protective factor for PPOI.

Risk prediction algorithms for prolonged postoperative ileus: A systematic review.

AIM: Prolonged postoperative ileus (PPOI) is common and is associated with a significant healthcare burden. Previous studies have attempted to predict PPOI clinically using risk prediction algorithms. The aim of this work was to systematically review and compare risk prediction algorithms for PPOI following colorectal surgery. METHOD: A systematic literature search was conducted using MEDLINE, Embase, Web of Science and CINAHL Plus. Studies that developed and/or validated a risk prediction algorithm for PPOI in adults following colorectal surgery were included. Data were collected on study design, population and operative characteristics, the definition of PPOI used and risk prediction algorithm design and performance. Quality appraisal was assessed using the PROBAST tool. RESULTS: Eleven studies with 87 549 participants were included in our review. Most were retrospective, single-centre analyses (6/11, 55%) and rates of PPOI varied from 10% to 28%. The most commonly used variables were sex (8/11, 73%), age (6/11, 55%) and surgical approach (5/11, 45%). Area under the curve ranged from 0.68-0.78, and only three models were validated. However, there was significant variation in the definition of PPOI used. No study reported sensitivity, specificity or positive/negative predictive values. CONCLUSION: Currently available risk prediction algorithms for PPOI appear to discriminate moderately well, although there is a lack of validation data. Future studies should aim to use a standardized definition of PPOI, comprehensively report model performance and validate their findings using internal and external methodologies.

Meckel's diverticulum is a rare cause of mechanical ileus in adults.

Meckel's diverticulum is the most common congenital gastrointestinal defect with a prevalence of 2%. It is mostly asymptomatic and it rarely causes acute abdomen in adults. In this case report, a 28-year-old male with no previous abdominal surgery presented with clinical symptoms of small bowel obstruction. Surgery revealed a Meckel's diverticulum adherent to the abdominal wall, causing internal herniation with small bowel obstruction. The diverticulum was openly resected and no post-operative complications occurred. Laparoscopy seems safe, and surgical removal of the symptomatic Meckel's diverticulum is recommended.

Effects of transcutaneous electrical nerve stimulation on recovery of gastrointestinal motility after laparotomy: A randomized controlled trial.

INTRODUCTION: Postoperative Ileus (POI) negatively impacts patient outcomes and increases healthcare costs. Transcutaneous electrical nerve stimulation (TENS) has been found to improve gastrointestinal (GI) motility following abdominal surgery. However, its effectiveness in this context is not well-established. This study was designed to evaluate the role of TENS on the recovery of GI motility after exploratory laparotomy. METHODS: Patients undergoing exploratory laparotomy were randomized in a 1:1 ratio into control (standard treatment alone) and experimental (standard treatment + TENS) arms. TENS was terminated after 6 days or after the passage of stool or stoma movement. The primary outcome was time for the first passage of stool/functioning stoma. Non-passage of stool or nonfunctioning stoma beyond 6 days was labeled as prolonged POI. Patients were monitored until discharge. RESULTS: Median (interquartile range) time to first passage of stool/functioning stoma was 82.6 (49-115) hours in the standard treatment group and 50 (22-70.6) hours in the TENS group [p < 0.001]. Prolonged POI was noted in 11 patients in the standard treatment group (35.5%) and one in the TENS group (3.2%) [p = 0.003]. Postoperative hospital stay was similar in the two groups. CONCLUSION: TENS resulted in early recovery of GI motility by shortening the duration of POI without any improvement in postoperative hospital stay. TRIAL REGISTRATION NUMBER: CTRI/2021/10/037054.

The impact of low pressure pneumoperitoneum in robotic assisted radical prostatectomy II: a prospective, randomized, double blinded trial.

OBJECTIVE: To analyze postoperative ileus rates and postoperative complications between the different pneumoperitoneum settings. The secondary objective was to evaluate narcotic use and intraoperative blood loss between the different pneumoperitoneum settings. METHODS: A prospective, randomized, double blinded study was conducted at pneumoperitoneum pressures of either 12 mmHg or 15 mmHg for patients undergoing robotic assisted radical prostatectomy with bilateral pelvic lymph node dissection by a single high volume surgeon. RESULTS: The risk of ileus in the 12 mmHg group was 1.9% (2/105) compared to 3.2% (3/93) in the 15 mmHg group (OR 0.58, 95%CI 0.1-3.6). There was no difference in the risk of any complication with a complication rate of 4.8% (5/105) in the 12 mmHg arm compared to 4.3% (4/93) in the 15 mmHg arm (OR 1.1, 95% CI 0.3 - 4.3). CONCLUSION: Pneumoperitoneum pressure setting of 12 mmHg has no significant difference to 15 mmHg in the rate of postoperative complications, narcotic use, and intraoperative bleeding. Additional research is warranted to understand the optimal.

Pyridostigmine to Reduce the duration of postoperative Ileus after Colorectal surgery (PyRICo-RCT): randomized clinical trial.

BACKGROUND: Postoperative ileus, driven by the cholinergic anti-inflammatory pathway, is the most common complication in patients undergoing colorectal surgery. By inhibiting acetylcholinesterase, pyridostigmine can potentially modulate the cholinergic anti-inflammatory pathway and accelerate gastrointestinal recovery. This study aimed to assess the efficacy of pyridostigmine in improving gastrointestinal recovery after colorectal surgery. METHODS: This double-blinded RCT enrolled adult patients undergoing elective colorectal surgery at two hospitals in South Australia. Patients were randomized to 60 mg oral pyridostigmine or placebo twice daily starting 6 h after surgery until the first passage of stool. The primary outcome was GI-2, a validated composite measure of time to first stool and tolerance of oral diet. Secondary outcomes included incidence of postoperative ileus (defined as GI-2 greater than 4 days), duration of hospital stay, and 30-day complications, evaluated by intention-to-treat univariate analysis. RESULTS: Of 130 patients recruited (mean(s.d.) age 58.4(16.4) years; 73 men, 56%), 65 were allocated to each arm. The median GI-2 was 1 day shorter with pyridostigmine compared with placebo (2 (i.q.r. 1-3) versus 3 (2-4) days; P = 0.015). However, there were no significant differences in postoperative ileus (17.2 versus 21.5%; P = 0.532) or duration of hospital stay (median 5 (i.q.r. 4-8.75) versus 5 (4-7.5) days; P = 0.921). Similarly, there were no significant differences in overall complications, anastomotic leak, cardiac complications, or patient-reported side effects. CONCLUSION: Pyridostigmine resulted in a quicker return of GI-2 and was well tolerated. Larger multicentre studies are required to determine the optimal dosing and evaluate the impact of pyridostigmine in different surgical settings. Registration number: ACTRN12621000530820 (https://anzctr.org.au).

Electroacupuncture treatment improves postoperative ileus by inhibiting the Th1 cell-mediated inflammatory response through the vagus nerve.

BACKGROUND: Electroacupuncture (EA) has been reported to improve intestinal motility in mice with postoperative ileus (POI). Previous studies, however, have yielded heterogeneous results regarding the effect of EA on POI. METHODS: Herein, a POI mouse model was constructed by intestinal manipulation. To evaluate the effect of EA treatment on colonic transit, the levels of inflammatory markers (macrophage inflammatory protein (MIP)-1α, interleukin (IL)-1ß, IL-6, monocyte chemotactic protein (MCP)-1 and intercellular adhesion molecule (ICAM)-1) were detected by enzyme-linked immunosorbent assay (ELISA); immune cell infiltration was detected by immunohistochemical staining of myeloperoxidase (MPO), ectodysplasin (ED)-1 and ED-2, and the percentage of CD4+ interferon (IFN)-γ+ Th1 cells and IFN-γ secretion levels were determined. Activated Th1 cells and pentoxifylline, a cell differentiation inhibitor, were used to assess the role of Th1 cells in EA treatment of POI. Neostigmine administration and unilateral vagotomy were performed to confirm whether the effects of EA treatment on Th1 cells were mediated by the vagus nerve (VN). RESULTS: The results revealed that EA treatment at ST36 improved POI, as indicated by a decreased level of inflammatory-related markers and immune cell infiltration and shortened colonic transit time. The activated Th1 cells abolished the effects of EA treatment on POI. The effects of EA treatment on POI were enhanced by stimulation of the VN along with a decreased level of Th1 cells, but these effects were abolished by vagotomy along with an increased percentage of Th1 cells; this result indicates that the VN mediates the role of Th1 cells in the effects of EA treatment of POI. CONCLUSION: Our findings showed that the effects of EA treatment of POI were mainly mediated by Th1 cells through the stimulation of the VN and inhibition of the inflammatory response.