Tube Feed Necrosis after Major Gastrointestinal Oncologic Surgery: Institutional Lessons and a Review of the Literature.

BACKGROUND: Small bowel necrosis after enteral feeding through a jejunostomy tube (tube feed necrosis, TFN) is a rare, serious complication of major abdominal surgery. However, strategies to reduce the incidence and morbidity of TFN are not well established. Here, in the largest series of TFN presented to date, we report our institutional experience and a comprehensive review of the literature. METHODS: Eight patients who experienced TFN from 2000 to 2014 after major abdominal surgery for oncologic indications at the University of Cincinnati were reviewed. Characteristics of post-operative courses and outcomes were reviewed prior to and after a change in tube-feeding protocol. The existing literature addressing TFN over the last three decades was also reviewed. RESULTS: Patients with TFN ranged from 50 to 74 years old and presented with upper gastrointestinal tract malignancies amenable to surgical resection. Six and two cases of TFN occurred following pancreatectomy and esophagectomy, respectively. Prior to TF protocol changes, which included initiation at a low rate, titrating up more slowly and starting at one-half strength TF, three of six cases of TFN (50%) resulted in mortality. With the new TF protocol, there were no deaths, goal TF rate was achieved 3 days later, symptoms of TFN were recognized 3 days earlier, and re-operation was conducted 1 day earlier. CONCLUSION: This case series describes a change in clinical practice that is associated with decreased morbidity and mortality of TFN. Wider implementation and further refinement of this tube-feeding protocol may reduce TFN incidence at other institutions and in patients with other conditions requiring enteral nutrition.

Incidence of and Risk Factors for Free Bowel Perforation in Patients with Crohn's Disease.

BACKGROUND: Incidence of and risk factors for intestinal free perforation (FP) in patients with Crohn's disease (CD) are not established. AIM: To establish rate of and risk factors for FP in a large cohort of CD patients. METHODS: Medical records of CD patients who visited Asan Medical Center from June 1989 to December 2012 were reviewed. After matching the FP patients to controls (1:4) by gender, year, and age at CD diagnosis, and disease location, their clinical characteristics were compared using conditional logistic regression analysis. RESULTS: Among 2043 patients who were included in our study cohort, 44 patients (2.15%) developed FP over a median follow-up period of 79.8 months (interquartile range 37.3-124.6), with an incidence of 3.18 per 1000 person-years [95% confidence interval (CI) 2.37-4.28]. All 44 patients underwent emergency surgery, and eight patients underwent reoperation within 12 months (8/44, 18.2%). Multivariable-adjusted analysis revealed that anti-TNF therapy [odds ratio (OR), 3.73; 95% CI 1.19-11.69; p = 0.024] was associated with an increased risk of FP. CONCLUSIONS: The incidence of FP in a large cohort of Korean CD patients was 2.15%, which was similar to that in Western reports. Anti-TNF therapy could be risk factors for FP.

Is every intussusception treatment an emergency intervention or surgery?

BACKGROUND: Intussusception is the second most common cause of acute abdomen in children, following appendicitis. The aim of the present study was to evaluate the experience of the authors, in an effort to promote intussusception management, especially that of small bowel intussusception. METHODS: Records of intussusception diagnosed between July 2002 and September 2014 were evaluated in terms of patient age, sex, clinical findings, admission time, ultrasonographic findings, treatment methods, and outcomes. RESULTS: Eighty-one patients, 52 males and 29 females, were included (mean age: 10.6 months). Intussusceptions were ileocolic (IC) in 52 cases, ileoileal (IL) in 26, and jejunojejunal (JJ) in 3. Nineteen (23.5%) patients underwent surgery. Hydrostatic reduction was performed in 45 (55.5%) IC cases. Seventeen (21%) patients with small bowel intussusceptions (SBIs), measuring 1.8-2.3 cm in length, spontaneously reduced. All patients who underwent surgery had intussusceptums ≥4 cm. Three of the 4 intestinal resection cases had history of abdominal surgery. CONCLUSION: If peritoneal irritation is present, patients with intussusception must undergo surgery. Otherwise, in patients with IC intussusception and no sign of peritoneal irritation, hydrostatic or pneumatic reduction is indicated. When this fails, surgery is the next step. SBIs free of peritoneal irritation and shorter than 2.3 cm tend to spontaneously reduce. For those longer than 4 cm, particularly in patients with history of abdominal surgery, spontaneous reduction is unlikely.

New insights into environmental enteric dysfunction.

Environmental enteric dysfunction (EED) has been recognised as an important contributing factor to physical and cognitive stunting, poor response to oral vaccines, limited resilience to acute infections and ultimately global childhood mortality. The aetiology of EED remains poorly defined but the epidemiology suggests a multifactorial combination of prenatal and early-life undernutrition and repeated infectious and/or toxic environmental insults due to unsanitary and unhygienic environments. Previous attempts at medical interventions to ameliorate EED have been unsatisfying. However, a new generation of imaging and '-omics' technologies hold promise for developing a new understanding of the pathophysiology of EED. A series of trials designed to decrease EED and stunting are taking novel approaches, including improvements in sanitation, hygiene and nutritional interventions. Although many challenges remain in defeating EED, the global child health community must redouble their efforts to reduce EED in order to make substantive improvements in morbidity and mortality worldwide.

Complications of gastrojejunal feeding tubes in children.

BACKGROUND: Long-term gastrojejunal (GJ) feeding is an increasingly popular alternative to gastric fundoplication for children with pathologic reflux, particularly those with neurologic impairment. We sought to evaluate morbidity associated with GJ feeding tubes in a large population of children. MATERIALS AND METHODS: The records of all children who underwent placement of a GJ feeding tube in a large children's hospital between January 2005 and September 2013 were reviewed. Indications for GJ feedings were noted. Events including a requirement for tube replacement and intestinal complications attributable to a GJ tube that required a laparotomy were evaluated. Risk factors for morbidity were assessed. RESULTS: A total of 124 children underwent GJ tube placement at an average age of 5.0 y (2 mo-16 y). Of the total, 83 (66%) subjects were neurologically impaired and 108 (87%) had gastroesophageal reflux. Of those, 55 (44%) had undergone prior laparoscopic fundoplication. Persistent reflux symptoms occurred in 22 (17.6%). Subjects underwent an average of 2.75 tube replacements per year and those under 2 y old had almost four. Four children (3.2%) required emergent laparotomy for intestinal perforation due to a GJ tube. These subjects were significantly younger (12 mo) than those without perforations (60.6 mo, P < 0.005). CONCLUSIONS: GJ feeding tubes were associated with notable morbidity ranging from persistent reflux to dislodgement and intestinal perforation. Together with issues of inconvenience with continuous feedings, these complications should be taken into account in children and particularly infants, in whom GJ feedings are being considered as an alternative to fundoplication.

The clinical characteristics of patients with free perforation in Korean Crohn's disease: results from the CONNECT study.

BACKGROUND: Free perforation is the most severe and debilitating complication associated with Crohn's disease (CD), and it usually requires emergency surgery. The aim of this study was to evaluate the incidence of free perforation among Korean patients with CD. METHODS: The CrOhn's disease cliNical NEtwork and CohorT (CONNECT) study was conducted nationwide in Korea, and patients who were diagnosed with CD between 1982 and 2008 were included in this retrospective study. We investigated the incidence of free perforation among these patients and their clinical characteristics. RESULTS: A total of 1346 patients were analyzed and 88 patients (6.5%) were identified with free perforation in CD. The mean age of the free perforation group was 31.8 ± 13.0 years, which was significantly higher than that of the non-perforated group (27.5 ± 12.1 years) (p = 0.004). Free perforation was the presenting sign of CD in 46 patients (52%). Of the 94 perforations that were present in 88 patients, 81 involved the ileum. Multivariate logistic regression analysis determined that free perforation was significantly associated with being aged ≥ 30 years at diagnosis (OR 2.082, p = 0.002) and bowel strictures (OR 1.982, p = 0.004). The mortality rate in the free perforation group was significantly higher (4.5%) than that in the non-perforated group (0.6%) (p < 0.001). CONCLUSION: The incidence of free perforation in Korean patients with CD was 6.5%. Being aged ≥ 30 years at CD diagnosis and bowel strictures were significant risk factors associated with free perforation.

Jejunal hematoma in cattle: a retrospective case analysis.

Sixteen years of adult cattle submissions to the California Animal Health and Food Safety Laboratory System were examined and data captured from cases with anaerobic cultures of intestinal content. Analysis was performed to determine if there were statistical differences between case submission types (nonbloody intestinal content [129 cases], bloody intestinal content [134 cases], and jejunal hematoma [JH; 51 cases]) for the presence of Clostridium perfringens (314 cases), C. perfringens toxinotypes (35 cases), and C. perfringens toxins (51 cases) in the content. Across submission types, significant differences were found in the isolation of C. perfringens between different specimen types (live cow, dead cow, or tissue from a field necropsy) with field samples being the most likely to have C. perfringens detected and live animals the least likely (P = 0.001). In cases of JH, detection of C. perfringens by enzyme-linked immunosorbent assay was more likely when a live or dead animal was submitted (P = 0.023) or when a live animal was submitted (P = 0.019) compared with submission of field necropsy tissues. These differences were not observed when cultures were performed to detect C. perfringens in cases of JH. There were no statistical differences between submission types with regard to any other variables evaluated. Detailed histologic examination of 21 cases of JH suggested disturbance of normal vascular or lymphatic function as the underlying problem in this entity.

The prevalence and outcome of jejunal lesions visualized by small bowel capsule endoscopy in Crohn's disease.

BACKGROUND: Small bowel capsule endoscopy is the most sensitive technique for the detection of lesions in the small intestine. The aims of the study were to assess the prevalence and clinical significance of jejunal lesions detected by small bowel capsule endoscopy in patients with an established Crohn's disease. RESULTS: One hundred and eight patients, including 32 patients with ileal disease, 25 patients with colonic disease, and 51 patients with ileocolonic disease, underwent small bowel capsule endoscopy, and findings were analyzed retrospectively. Jejunal lesions were detected in 56% of these patients, of whom 18 (17%) had lesions only in the jejunum. Jejunal lesions were less frequently detected (12% versus 38%, P = 0.001) when location of the disease was limited to the colon at ileocolonoscopy. Conversely, when Crohn's disease affected the ileum, jejunal lesions were more frequently detected (40% versus 17%, P = 0.007). During a median follow-up time of 24.0 months (interquartile, 8.0-46.2), 50 clinical relapses occurred. The presence of jejunal lesions was the only independent factor associated with an increased risk of relapse (P = 0.02). In nonsmokers and in patients treated by immunosuppressors, the presence of jejunal lesions tended to increase the risk of relapse (P = 0.06 and 0.05, respectively). CONCLUSIONS: Jejunal lesions are detected in more than half of the patients with Crohn's disease. The prevalence of jejunal lesions is higher when the terminal ileum is involved and associated with an increased risk of further clinical relapse. It may be regarded as a factor of severity.

Linear-stapled gastrojejunostomy with transverse hand-sewn enterotomy closure significantly reduces strictures for laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Gastrojejunostomy (GJ) stricture is a common complication after Roux-en-Y gastric bypass (RYGB) for morbid obesity, and the optimal anastomotic technique remains uncertain. The objective of this study was to use cumulative summation (CUSUM) analysis to compare rates of gastrojejunostomy strictures after linear stapling with longitudinal versus transverse enterotomy closure in gastric bypass patients. METHODS: Charts of all consecutive patients with at least 60 days of post-operative follow-up after laparoscopic RYGB (LRYGB) at our tertiary care institution from Nov 2009 to Dec, 2011 were retrospectively reviewed. Gastrojejunostomy stricture was diagnosed by history and upper endoscopy. CUSUM method of quality control analysis was used to determine sequential improvement in stricture rates with the change in technique. RESULTS: A total of 197 patients were included (97 longitudinal closure, median age 44 (21-67), median BMI 47 (35-80), 85.8 % female). Gastrojejunostomy strictures occurred in 16 % of longitudinal and 0 % of transverse patients (p = <0.0001). CUSUM analysis demonstrated sequential statistically significant improvement in stricture rates after the change in technique was applied. The longitudinal group had a statistically significant increased rate of surgery-related readmissions (15.5 vs 6.0 %, p = 0.038), with 43.7 % of those readmissions related to GJ strictures. There were no other significant outcome differences between groups. CONCLUSIONS: Linear-stapled anastomosis with a transverse enterotomy closure significantly reduces the rate of gastrojejunostomy stricture for LRYGB, considerably reducing procedural morbidity.

Risk of adhesive obstruction after colorectal surgery: the benefits of the minimally invasive approach may extend well beyond the perioperative period.

BACKGROUND: Risk of adhesive small-bowel obstruction (SBO) is high following open colorectal surgery. Laparoscopic surgery may induce fewer adhesions; however, the translation of this advantage to a reduced rate of bowel obstruction has not been well demonstrated. This study evaluates whether SBO is lower after laparoscopic compared with open colorectal surgery. METHODS: Patients who underwent laparoscopic abdominal colorectal surgery, without any previous history of open surgery, from 1998 to 2010 were identified from a prospective laparoscopic database. Details regarding occurrence of symptoms of SBO (colicky abdominal pain; nausea and/or vomiting; constipation; abdominal distension not due to infection or gastroenteritis), admissions to hospital with radiological findings confirming SBO, and surgery for obstruction after the laparoscopic colectomy were obtained by contacting patients and mailed questionnaires. Patients undergoing open colorectal surgery for similar operations during the same period and without a history of previous open surgery also were contacted and compared with the laparoscopic group for risk of obstruction. RESULTS: Information pertaining to SBO was available for 205 patients who underwent an elective laparoscopic procedure and 205 similar open operations. The two groups had similar age, gender, and sufficiently long duration of follow-up. Despite a significantly longer duration of follow-up for the laparoscopic group, admission to hospital for SBO was similar between groups. Patients who underwent laparoscopic surgery also had significantly lower operative intervention for SBO (8% vs. 2%, p = 0.006). CONCLUSIONS: Although the rate of SBO was similar after laparoscopic and open colorectal surgery, the need for operative intervention for SBO was significantly lower after laparoscopic operations. These findings especially in the context of the longer follow-up for laparoscopic patients suggests that the lower incidence of adhesions expected after laparoscopic surgery likely translates into long-term benefits in terms of reduced SBO.

Concurrent nephrosplenic entrapment and acquired inguinal herniation of the jejunum in a Standardbred stallion.

A stallion presenting for surgical correction of an acquired inguinal hernia was also diagnosed with a nephrosplenic entrapment (NSE) intraoperatively. Surgical intervention resulted in a successful outcome. To date, these conditions have not been reported to occur simultaneously.

Refractory strictures after Roux-en-Y gastric bypass: operative management.

BACKGROUND: Stricture of the gastrojejunostomy after Roux-en-Y gastric bypass (RYGB) is common in the early postoperative period, with a reported incidence of 3-27%. Late recalcitrant strictures are much less common. Treatment has varied from endoscopic therapy to operative revision of the gastrojejunostomy with or without additional anatomic revisions. The origin of the late strictures varies, with the most common causes being excessive acid, aspirin, or nonsteroidal anti-inflammatory drug use, postoperative anastomotic leak, or, as some have maintained, smoking. We sought to identify the predictors of gastrojejunostomy strictures that require operative management after RYGB and to evaluate the clinical outcomes of patients requiring operative revision of the gastrojejunostomy stricture after failed nonoperative therapy at an academic institution. METHODS: A retrospective review was performed of all patients undergoing operative intervention for gastrojejunostomy stricture from 1990 to 2009 after having undergone RYGB for medically complicated obesity. RESULTS: A total of 24 patients required revision of their gastrojejunostomy stricture after multiple attempts at nonoperative therapy. The mean interval from RYGB to reoperation was 4.3 years (range .5-25). The interval to operative revision for anastomotic stricture was substantially less in patients with active anastomotic ulcers (n = 6), those who had had a gastrojejunostomy leak after RYGB (n = 5), and those with gastrogastric fistulas (n = 7; 20, 23, and 44 months, respectively). Of the 24 patients, 23 experienced relief of their symptoms. The postoperative morbidity rate was 21%, and the mortality rate was 0%. CONCLUSION: Operative revision of strictured gastrojejunostomy is a safe and effective procedure for those patients in whom endoscopic therapy has failed. Most refractory anastomotic strictures have been secondary to excessive acid (too large a proximal pouch), chronic ulceration, or postoperative anastomotic leak.

Should we be concerned about jejunoileal atresia during repair of duodenal atresia?

INTRODUCTION: During repair for duodenal atresia, it has been emphasized that inspection of the small bowel to identify a second atresia is required. The laparoscopic approach for repair of duodenal atresia has been criticized for its limitation to perform this step. Given that duodenal atresia and jejunoileal atresias do not share common embryologic origins, we question the validity of this concern. Therefore, we conducted a multicenter retrospective review of duodenal atresia patients to quantify the incidence of jejunoileal atresia in this population. METHODS: After institutional review board approval (IRB #07-12-187X), a retrospective review was conducted on all patients who have undergone duodenal atresia repair at seven institutions over the past 7-12 years. Demographics and the presence or absence of a jejunoileal atresia were recorded. RESULTS: Four hundred eight patients with duodenal atresia were identified. The mean gestaational age was 36.3 ± 2.9 weeks, and the mean weight was 2.5 ± 0.8 kg. Mean age at operation was 19 days (range, 1-1314). There was a 28% incidence of trisomy 21. Two patients (0.5%) were identified as having a second intestinal atresia, and both were type IIIb. One patient was diagnosed at the time of duodenal atresia repair; the other was a delayed diagnosis. Both patients did well after repair. CONCLUSIONS: In this, the largest series of duodenal atresia patients compiled to date, the rate of a concomitant jejunoileal atresia is less than 1%. This low incidence is not high enough to mandate extensive inspection of the entire bowel in these patients, and a second atresia should not be a concern during laparoscopic repair of duodenal atresia.

Stenosis of esophago-jejuno anastomosis after gastric surgery.

BACKGROUND: Stenosis of esophago-jejuno anastomosis is one of the postoperative complications of gastric surgery. This complication usually manifests with the symptom of dysphagia and is treated by endoscopic dilatation. No large-scale studies have been conducted to determine the incidence of this complication after surgery. METHODS: The data of a total of 1478 consecutive patients who underwent total, proximal, or completion gastrectomy, including esophago-jejuno anastomosis, between 2000 and 2008 were analyzed retrospectively with a view to determining the incidence of anastomotic stenosis. RESULTS: Sixty patients (4.1%) developed stenosis of the esophago-jejuno anastomosis which needed to be treated by endoscopic balloon dilatation. The average interval between the surgery and detection of stenosis was 67.4 days (median = 58.0). Multivariate analysis identified female gender, proximal gastrectomy, use of a narrow-sized stapler, and the choice of the stapling device as significant factors influencing the risk of development of anastomotic stenosis. CONCLUSION: Esophago-jejuno anastomotic stenosis appears to be a common late postoperative complication after gastric surgery. Endoscopic examination and treatment yielded favorable outcomes in patients complaining of dysphagia after gastric surgery.

Adult intussusception - 14 case reports and their outcomes.

AIMS: To analyze diagnostic and therapeutic options depending on the clinical symptoms, location, and lesions associated with intussusception, together with their follow-up and complications. PATIENTS AND METHODS: Patients admitted to the Morales Meseguer General University Hospital (Murcia) between January 1995 and January 2009, and diagnosed with intestinal invagination. Data related to demographic and clinical features, complementary explorations, presumptive diagnosis, treatment, follow-up, and complications were collected. RESULTS: There were 14 patients (7 males and 7 females; mean age: 41.9 years-range: 17-77) who presented with abdominal pain. The most reliable diagnostic technique was computed tomography (8 diagnoses from 10 CT scans). A preoperative diagnosis was established in 12 cases. Invaginations were ileocolic in 8 cases (the most common), enteric in 5, and colocolic in 2 (coexistence of 2 lesions in one patient). The etiology of these intussusceptions was idiopathic or secondary to a lesion acting as the lead point for invagination. Depending on the nature of this lead point, the cause of the enteric intussusceptions was benign in 3 cases and malignant in 2. Ileocolic invaginations were divided equally (4 benign and 4 malignant), and colocolic lesions were benign (2 cases). Conservative treatment was implemented for 4 patients and surgery for 10 (7 in emergency). Five right hemicolectomies, 3 small-bowel resections, 2 left hemicolectomies, and 1 ileocecal resection were performed. Surgical complications: 3 minor and 1 major (with malignant etiology and subsequent death). The lesion disappeared after 3 days to 6 weeks in patients with conservative management. Mean follow-up was 28.25 months (range: 5-72 months). CONCLUSIONS: A suitable imaging technique, preferably CT, is important for the diagnosis of intussusception. Surgery is usually necessary but we favor conservative treatment in selected cases.

Chronic bilious vomiting in children in developing countries due to high bowel obstruction: not always malrotation or tuberculosis.

BACKGROUND: Bilious vomiting, in conjunction with abdominal pain is considered to be a surgical problem, unless proved otherwise. In children, besides tuberculosis (TB), we have found jejunal stricture (JS) due to non-specific jejunoileitis (NSJI) to be an important cause of chronic high small bowel obstruction and bilious vomiting. MATERIALS AND METHODS: In this retrospective study, the records of all children with complaint of intermittent bilious vomiting and failure to thrive were evaluated. Investigations included oral contrast study, ultrasound abdomen, chest X-ray and Mantoux test. Final confirmation was made at laparotomy. Treatment included jejuno-jejunal resection and anastomosis. Histopathology of the specimen was done to look for caseation, granuloma formation and other details. RESULTS: Out of total 100 patients with the complaint of bilious vomiting, 25 were having JS. Radiologic confirmation was possible in 19 (76%) patients of JS. No patient had evidence of TB as per our protocol. Histopathology revealed non-specific ischemic changes in all specimens. CONCLUSION: Jejunal stricture due to NSJI is a common entity in our setup leading to bilious vomiting. Contrast study can provide high index of suspicion in most of the patients. The diagnosis must be confirmed after proper histopathological examination. The results of the surgery are excellent.

Complicated jejunal diverticula as surgical emergency: experience at a tertiary care hospital in Peshawar, Pakistan.

BACKGROUND: Diverticula of small intestine are rare. Jejunal diverticula can be single or multiple. Diverticula in the jejunum tend to be large and multiple. Clinically they may be asymptomatic or may give rise to symptoms like pain, flatulence and borborygmi, may produce malabsorption syndrome or may present in emergency with different acute pathologies like perforation, haemorrhage, obstruction, enterolith formation and inflammation. The Objective was to see the pattern of complications in jejunal diverticula presenting as a surgical emergency. METHODS: This descriptive study was conducted at Surgical Units of the 3 tertiary care Hospitals of Peshawar, for 7 years from January 1, 2002 to December 31, 2008. Study included all patients presenting to and admitted in Surgical Unit, Hayatabad Medical Complex, Peshawar with complicated jejunal diverticula during the above mentioned period. Name, age, sex, other relevant data, history and examination findings and results of investigation were recorded. Uncomplicated jejuna diverticula were excluded from study. The operative findings and the type of complication were recorded. RESULTS: Ten patients were admitted during 7 years of study. Out of all patients 9 were male and 1 was female. Eight out of 10 patients presented with perforation of diverticula while 1 patient had severe inflammation of diverticulum causing pain, ileus and acute abdomen. One patient had acute pain due to adhesion formation. CONCLUSION: It is seen that complicated jejunal diverticulae are quite rare and the most common complication is perforation. Inflammation and adhesion are other complications with which jejunal diverticula presented during this study.