Prehabilitation Before Gastrointestinal Cancer Surgery: Protocol for an Implementation Study.

BACKGROUND: Surgery remains the standard curative treatment for early-stage colorectal and upper gastrointestinal cancer. Reduced preoperative functional capacity, nutritional status, and psychological well-being are associated with poor postoperative outcomes. Prehabilitation aims to improve preoperative functional reserves through physical, nutritional, and psychological interventions. Yet, how it transitions from a trial setting to being integrated into a real-world health setting is unknown. OBJECTIVE: The primary aim is to evaluate the implementation of a multimodal (supervised exercise, nutrition, and nursing support) prehabilitation program into standard care for patients with gastrointestinal cancer (colorectal and upper gastrointestinal cancer) scheduled for curative intent surgery. The secondary aim is to determine the impact of a multimodal prehabilitation program on functional capacity, nutritional and psychological status, and surgical outcomes. METHODS: This is an implementation study that will investigate a multimodal prehabilitation intervention, in a nonblinded, nonrandomized, single-group, pre-post design. Patients diagnosed with colorectal and upper gastrointestinal cancer scheduled for potentially curative intent surgery at Concord Repatriation General Hospital, with ≥14 intervention days prior to surgery and are medically cleared to exercise will be eligible. The study will be evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Evaluation Framework. RESULTS: The protocol was approved in December 2019 by the Concord Repatriation General Hospital Human Research Ethics Committee (reference number 2019/PID13679). Recruitment commenced in January 2020. In response to the COVID-19 pandemic, recruitment was paused in March 2020 and reopened in August 2020 with remote or telehealth intervention adaptations. Recruitment ended on December 31, 2021. Over the 16-month recruitment period, a total of 77 participants were recruited. CONCLUSIONS: Prehabilitation represents an opportunity to maximize functional capacity and improve surgical outcomes. The study will provide guidance and contribute to the evidence on the integration of prehabilitation into standard care using adaptive models of health care delivery including telehealth. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTR 12620000409976; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378974&isReview=true. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/41101.

Endoscopic lithotripsy for Bouveret syndrome complicated by small bowel obstruction secondary to gallstone fragments.

Bouveret syndrome is a rare complication of cholecystitis, in which impaction of a gallstone creates a cholecystoduodenal fistula leading to gastric outlet obstruction. We report a case of a 90-year-old female who presented with nausea and vomiting on a background of previous necrotic cholecystitis managed conservatively. Computed tomography of the abdomen demonstrated a large gallstone impacted in the third part of the duodenum leading to gastric outlet obstruction. Given her frailty, the patient underwent endoscopy to relieve the obstruction; however, complete retrieval of the gallstone fragments after lithotripsy was not possible. She subsequently developed distal gallstone ileus due to migration of the gallstone fragments and underwent laparotomy, enterotomy and retrieval of the fragments. This case highlights the dilemma of managing elderly patients with Bouveret syndrome with open or endoscopic surgery and the importance of retrieving all gallstone fragments after lithotripsy to avoid iatrogenic complications, such as gallstone ileus.

Can we measure surgical resilience?

Surgical resilience describes psychological resilience within a surgical setting. Within a surgical setting, psychologically resilient patients have improved recovery and wound-healing. The search for biological correlates in resilient patients has led to the hypothesis that certain endogenous biomarkers (namely neuropeptide Y (NPY), testosterone, and dehydroepiandrosterone (DHEA)) are altered in resilient patients. The concept of surgical resilience raises the question of whether enhanced recovery following surgery can be demonstrated in patients with high titres of resilience biomarkers as compared to patients with low titres of resilience biomarkers. To determine the prognostic value of resilience biomarkers in surgical recovery, a cohort of patients undergoing major surgery should initially be psychometrically tested for their resilience levels before and after surgery so that biomarker levels of NPY, testosterone and DHEA can be compared to a validated psychometric test of resilience. The primary outcome would be length of hospital stay with and without an enhanced recovery program. Secondary outcome measures such as complications, time in rehabilitation and readmission could also be included. If the hypothesis is upheld, resilience biomarkers could be used to support more individualised perioperative management and lead to more efficient and effective allocation of healthcare resources.

Surgical resilience: a review of resilience biomarkers and surgical recovery.

BACKGROUND: Two distinct and large bodies of literature exist on resilience that are of potential interest for surgical outcomes. First is the literature on the impact of resilience on surgical recovery and wound-healing. Second is the literature on biomarkers for resilience, which largely focuses on neuropeptide Y (NPY), testosterone and dehydroepiandrosterone (DHEA). Despite this activity, there is a dearth of literature linking these two bodies of research by investigating biomarkers for surgical resilience and its impact on surgical recovery. This paper reviews both bodies of literature within the context of surgical recovery. METHOD: Literature searches within Medline and Embase were conducted for studies and previous reviews of resilience biomarkers and for the impact of individual resilience on surgical recovery. Reference lists of the reviews were searched for additional papers. No systematic review is yet possible due to the novelty of the use of resilience biomarkers within a surgical context. RESULTS: This is the first review to explore a potential link between resilience biomarkers and surgical recovery. There are a number of biomarkers that correlate with individual resilience levels and resilient individuals exhibit better recovery trajectories following surgery, suggesting a novel use of such biomarkers for the identification of "surgical resilience". CONCLUSION: By identifying surgical resilience, there is potential for utilising these biomarkers as prognostic indicators of likely recovery trajectories from surgery, which in turn complement individualised peri-operative management.

On the road to single-site laparoscopic adjustable gastric banding: lessons learned from 60 cases.

BACKGROUND: Single-site laparoscopic surgery is a promising emerging technique with potential to decrease postoperative pain, reduce port-site complications, and improve cosmetic results. Laparoscopic adjustable gastric banding (LapGB) is a procedure that lends itself well to single-site laparoscopic surgery because the surgery is confined to a single region of the body, the need for a larger incision for port implantation and the fact that bariartric patients are more likely to be body image conscious. The procedure is, however, technically challenging and potentially more time consuming and hazardous. To simplify learning, a hybrid technique that used multiple conventional trocars and laparoscopic equipment through a single periumbilical incision while retaining the use of the Nathanson retractor via a separate epigastric incision was developed. The authors' experience and results with this technique are described. METHODS: This retrospective review describes the prospectively collected data for the first 60 consecutive cases completed using the minimally invasive technique described. RESULTS: The 60 cases in this study comprised 12 men and 48 women with an average age of 39 years (range 20-59 years). Their average body mass index (BMI) was 39.1 kg/m(2) (range 32-52 kg/m(2)). Four patients (6.7%) needed an additional port either for hemostasis or for access difficulties. Concomitant hiatal hernia repair was performed for 13 patients. Five patients (8.3%) had superficial wound infection requiring oral antibiotic therapy and dressings. No other complications were observed. Overall, the average operating time was 55 min (range 30-160 min). For both surgeons, the learning curve was six cases, with a significant difference in the operating times between the first six cases and the remaining cases (p < 0.0001, Mann-Whitney U test). CONCLUSIONS: The authors' early experience with the minimally invasive LapGB technique shows that it is feasible and safe. It can be used either as a bridging technique to single-site LapGB or on its own as a minimally invasive technique.

[Multiple colonic anastomoses in the surgical treatment of short bowel syndrome. A new technique]. / Anastomosis colónica múltiple en el tratamiento quirúrgico del intestino corto. Una nueva técnica.

BACKGROUND: Some surgical pathologies eventually require intestinal resection. This may lead to an extended procedure such as leaving 30 cm of proximal jejunum and left and sigmoid colon. One of the most important consequences of this type of resection is "intestinal failure" or short bowel syndrome. This complex syndrome leads to different metabolic and water and acid/base imbalances, as well as nutritional and immunological challenges along with the problem accompanying an abdomen subjected to many surgical procedures and high mortality. Many surgical techniques have been developed to improve quality of life of patients. METHODS: We designed a non-transplant surgical approach and performed the procedure on two patients with postoperative short bowel syndrome with <40 cm of proximal jejunum and left colon. RESULTS: There are a variety of non-transplant surgical procedures that, due to their complex technique or high mortality rate, have not resolved this important problem. However, the technique we present in this work can be performed by a large number of surgeons. The procedure has a low morbimortality rate and offers the opportunity for better control of metabolic and acid/base balance, intestinal transit and proper nutrition. CONCLUSIONS: We consider that this technique offers a new alternative for the complex management required by patients with short bowel syndrome and facilitates their long-term nutritional control.

Anastomosis colónica múltiple en el tratamiento quirúrgico del intestino corto: una nueva técnica / Multiple colonic anastomoses in the surgical treatment of short bowel syndrome: a new technique

BACKGROUND: Some surgical pathologies eventually require intestinal resection. This may lead to an extended procedure such as leaving 30 cm of proximal jejunum and left and sigmoid colon. One of the most important consequences of this type of resection is [quot ]intestinal failure[quot ] or short bowel syndrome. This complex syndrome leads to different metabolic and water and acid/base imbalances, as well as nutritional and immunological challenges along with the problem accompanying an abdomen subjected to many surgical procedures and high mortality. Many surgical techniques have been developed to improve quality of life of patients. METHODS: We designed a non-transplant surgical approach and performed the procedure on two patients with postoperative short bowel syndrome with <40 cm of proximal jejunum and left colon. RESULTS: There are a variety of non-transplant surgical procedures that, due to their complex technique or high mortality rate, have not resolved this important problem. However, the technique we present in this work can be performed by a large number of surgeons. The procedure has a low morbimortality rate and offers the opportunity for better control of metabolic and acid/base balance, intestinal transit and proper nutrition. CONCLUSIONS: We consider that this technique offers a new alternative for the complex management required by patients with short bowel syndrome and facilitates their long-term nutritional control.

[Ileocecal valve lipoma. Case report and review of the literature]. / Lipoma de la válvula ileocecal. Informe de un caso clínico y revisión de la literatura.

BACKGROUND: Lipomas are the most frequent benign tumors of the digestive tract and 50% are localized in the colon. Most are found submucosally and may vary in their incidence, localization, symptoms and pathogenesis, making diagnosis difficult. We undertook this study to learn the different presentations of an ileocecal valve (ICV) lipoma and conduct a review of the literature due to this uncommon location. CASE PRESENTATION: We present the case of a 78-year-old female with intermittent small bowel occlusion, abdominal distention and constipation. Colonoscopy showed a submucous tumor at the ICV, CT scan showed a tumor at the ICV with fat density. Laparotomy was performed with primary resection of the lesion by cecotomy, frozen section was reported as nonmalignant so a primary closure without ICV involvement was achieved. Definitive pathology revealed a benign lipoma. CONCLUSION: It is important to know the different presentations of these benign tumors because if there is mucosal ulceration they can be mistaken for a malignant lesion and lead to greater resections. Resection is necessary if they are symptomatic or >2 cm.

[Laparoscopic appendectomy. Present situation. ABC medical center experience during the last five years]. / Apendicectomia laparoscópica. Lugar actual. Experiencia del Centro Médico ABC en los ultimos cinco años.

OBJECTIVE: To compare the diagnostic and therapeutic accuracy of laparoscopic appendectomy versus open appendectomy. BACKGROUND DATA: Appendectomy is the treatment of choice for acute appendicitis. Open Appendectomy (OA) has its complications rates (10-20%) and negative explorations in young women are about 25-30%. Acute appendicitis has a 3.1% morbidity and with perforation up to 47.2% and a mortality rate less than 1%. Advantages of laparoscopic appendectomy (LA) has been shown in many studies with lower intraoperatory and postoperatory complications, less hospitalization days, lower pain and faster return to daily activities when its compared with OA. METHODS: We perform a retrospective and descriptive trial with 1,883 patients with acute appendicitis between January 2000 to September 2004. Patients smaller than 15 years old and with other postoperatory diagnosis were excluded. Ji2 and t Student statistic tests were performed. RESULTS: We obtained 1,272 patients with acute appendicitis, 49% male and 51% female. LA was performed in 732 patients, 46.1% male and 53.9% female and OA was performed in 541 patients, 52.6% male and 47.3% female. Similar midage patients in both groups. LS was performed in 180 patients with complicated appendicitis and 116 patients by OA. LA was converted to open surgery in 4.5% patients. Morbidity was lower for laparoscopic group with statistical difference. There were no difference in fasting and hospitalization days. CONCLUSIONS: This procedure is a good choice for differential diagnosis overall in young women and complicated appendicitis with lower morbidity than the OA.

[Refundoplication for failed antireflux surgery. Experience in sixteen cases]. / Refunduplicatura por cirugía antirreflujo fallida. Experiencia en 16 casos.

BACKGROUND: We undertook this study to identify the main causes leading to a failed funduplication and to determine the feasibility and effectiveness of reoperation by laparoscopic approach. METHODS: A retrospective and descriptive study was carried out with a review of patient charts. Patients were reoperated for failed antireflux surgery between January 1999 and September 2004. RESULTS: Sixteen patient charts were reviewed, 10 men (62.5%) and 6 women (37.5%), average age 42.1 +/- 15.4 years (21 to 72 years). Main preoperative symptoms were severe reflux in seven patients (43.7%), severe dysphagia in five (31.3%), and dysphagia and pain in four (25%). Thirteen patients (81%) had previous Nissen laparoscopic funduplication (NL), one (6%) open Nissen (ON) and two (13%) open Toupet (OT). Four patients were reoperated with open surgery (two Nissen and two Toupet), and 12 laparoscopically (11 Nissen and 1 Toupet). The main causes of dysfunction were a) in LN: sliding of the funduplication in five patients (38%), angulation of the funduplication in three (23%) and others; b) in ON: sliding of the funduplication in one patient; and c) in OT: posterior sliding of the funduplication in two cases. The hospital stay for the laparoscopic group was 3.5 +/- 1 days (2 to 5 days) and for the open group, 5.2 +/- 1.3 days (4 to 7 days, p < 0.013, Student t-test). Morbidity 1 month postoperatively was 37.5%. Also reported were abdominal distention (19%), occasional distention with dysphagia (12%), reflux (6.5%), with 0% mortality. CONCLUSIONS: Laparoscopic reoperation for failed antireflux surgery is feasible with an acceptable morbidity and good results.

[Intraoperative endoscopy in laparoscopic fundoplications]. / Endoscopia transoperatoria en funduplicatura laparoscópica.

BACKGROUND: Laparoscopic fundoplications are the standard surgical treatment of patients with gastroesophageal reflux disorder. Adequate technique is the most important outcome factor. There is no standardized method to evaluate the procedure itself. Intraoperative endoscopy is a method to evaluate laparoscopic fundoplications. MATERIAL AND METHODS: This was a retrospective observational study of patients undergoing laparoscopic fundoplications from July 1999 to June 2004, excluding open procedures and reoperations of previous failed laparoscopic fundoplications. Intraoperative endoscopy was performed during the dissection and suturing of the procedure to determine if correction of the technique is necessary. Number of changes were recorded and analyzed with Student's t-test. RESULTS: Three hundred patients were operated on, 23 were excluded (14 reoperations and nine conventional laparotomies). Of the 277 patients included, 178 were males and 99 females. Average age was 43.4 +/- 14 years (range: 12-85). There were 71 Toupet and 206 Nissen fundoplications. Intraoperative endoscopy determined correction of the technique in 77 patients with 1.69 +/- 0.96 changes; 68 rotated and/or angled fundoplications, one rotation with distended stomach, one redundant gastric fundus, and seven change in the type of fundoplication from Nissen to Toupet because of tightness (3.7 +/- 1.1 changes, p = 0.0001) to achieve adequate fundoplication. CONCLUSIONS: Intraoperative endoscopy confirms adequate technique and prevents inadequate laparoscopic fundoplications. Further studies will determine if routine use is justified to prevent postoperative complications and to improve outcome.

Lipoma de la válvula ileocecal: informe de un caso clínico y revisión de la literatura / Ileocecal valve lipoma: case report and review of the literature

Introducción: los lipomas son los tumores benignos más frecuentes en tubo digestivo y hasta 50 % se encuentra en el colon. La mayoría son submucosos y varían de acuerdo a su incidencia, localización, sintomatología y patogénesis, lo que dificulta su diagnóstico. Nuestro objetivo fue conocer las diferentes manifestaciones clínicas causadas por un lipoma en la válvula ileocecal, y hacer una revisión de la literatura de esta localización poco frecuente. Caso clínico: mujer de 78 años que presentó cuadros repetidos de oclusión intestinal parcial con distensión abdominal, constipación y obstipación. Se realizó colonoscopia que mostró tumoración submucosa de 30 mm en válvula ileocecal; la tomografía computarizada de abdomen mostró tumoración nodular de densidad grasa en válvula ileocecal. La paciente fue sometida a laparotomía exploradora y cecotomía, donde se identificó y resecó tumoración submucosa, la cual fue enviada a estudio transoperatorio; dado que se trató de una tumoración benigna, se respetó la válvula ileocecal y se realizó cierre primario. El reporte histopatológico definitivo fue lipoma, negativo para malignidad. Conclusiones: es importante conocer las distintas formas de presentación de los lipomas, ya que fácilmente pueden confundirse con lesiones malignas (sobre todo si existe ulceración de la mucosa) y someter al paciente a procedimientos mayores. Sólo deben resecarse si producen síntomas o son mayores a 2 cm.

BACKGROUND: Lipomas are the most frequent benign tumors of the digestive tract and 50% are localized in the colon. Most are found submucosally and may vary in their incidence, localization, symptoms and pathogenesis, making diagnosis difficult. We undertook this study to learn the different presentations of an ileocecal valve (ICV) lipoma and conduct a review of the literature due to this uncommon location. CASE PRESENTATION: We present the case of a 78-year-old female with intermittent small bowel occlusion, abdominal distention and constipation. Colonoscopy showed a submucous tumor at the ICV, CT scan showed a tumor at the ICV with fat density. Laparotomy was performed with primary resection of the lesion by cecotomy, frozen section was reported as nonmalignant so a primary closure without ICV involvement was achieved. Definitive pathology revealed a benign lipoma. CONCLUSION: It is important to know the different presentations of these benign tumors because if there is mucosal ulceration they can be mistaken for a malignant lesion and lead to greater resections. Resection is necessary if they are symptomatic or >2 cm.

[Sclerosing encapsulated peritonitis. Diagnostic and therapeutic challenge for the general surgeon]. / Peritonitis esclerosante encapsulante. Reto diagnóstico y terapéutico para el cirujano general.

Intestinal obstruction is one of the most frequently abdominal problems that concern general surgeons. One of the infrequent causes of mechanical obstruction is sclerosing encapsulating peritonitis (SEP); this entity causes intense fibrosis of the components in the peritoneal layer, resulting in adhesion of abdominal organs. SEP can be primary or secondary; both are a type of peritoneal fibrosclerosis that causes intestinal obstruction with difficult resolution and a great number of complications. In terms of frequency and etiology, there are few data, and the problem is considerated a multifactorial disease with association to neoplasms, toxics, drugs, and idiopathic form. This article presents three cases of sclerosing encapsulating peritonitis and the possible factors that play an important role in the development of this infrequent entity.