From intestinal failure to transplantation: Review on the current need for transplant indications under multidisciplinary transplant programs worldwide.

INTRODUCTION: Intestinal failure, defined as the loss of gastrointestinal function to the point where nutrition cannot be maintained by enteral intake alone, presents numerous challenges in children, not least the timing of consideration of intestine transplantation. OBJECTIVES: To describe the evolution of care of infants and children with intestinal failure including parenteral nutrition, intestine transplantation, and contemporary intestinal failure care. METHODS: The review is based on the authors' experience supported by an in-depth review of the published literature. RESULTS: The history of parenteral nutrition, including out-patient (home) administration, and intestine transplantation are reviewed along with the complications of intestinal failure that may become indications for consideration of intestine transplantation. Current management strategies for children with intestinal failure are discussed along with changes in need for intestine transplantation, recognizing the difficulty in generalizing recommendations due to the high level of heterogeneity of intestinal pathology and residual bowel anatomy and function. DISCUSSION: Advances in the medical and surgical care of children with intestinal failure have resulted in improved transplant-free survival and a significant fall in demand for transplantation. Despite these improvements a number of children continue to fail rehabilitative care and require intestine transplantation as life-saving therapy or when the burden on ongoing parenteral nutrition becomes too great to bear.

[Indications and results of intestinal transplantation for short bowel syndrome after mesenteric ischemia]. / Indikation und Ergebnisse der Darmtransplantation bei Kurzdarmsyndrom nach mesenterialer Ischämie.

BACKGROUND: Intestinal transplantation (ITx) is the only causal treatment for complicated chronic intestinal failure after mesenteric ischemia and impending failure of parenteral supplementation. Isolated or combined ITx with the inclusion of the intestine is associated with demanding immunological, perioperative and infection associated challenges. AIM: The characterization of chronic intestinal failure, the indications, transplant survival, transplantation techniques and success rates. MATERIAL AND METHODS: Collection, summary and critical appraisal of international guidelines, the guidelines of the German Medical Chamber, and the international literature. RESULTS: The first successful ITx were performed in 1987 and 1988 at the University of Kiel Germany and the University of Pittsburgh, USA. The number of ITx rose continuously but in phases from the end of the 1990s to over 200 per year but has currently decreased to 100-150 per year due to optimized intestinal rehabilitation. While the 1­year and 3­year transplant survival rates were 30% and 20% before 1991, they increased in phases up to 60% and 50%, respectively, after 1995 and have now achieved almost 80% and 70%, respectively. CONCLUSION: The substantial improvement in the results of ITx can be partly explained by progress in operative techniques, intensive care medicine and a better understanding of mucosal immunity; however, optimized strategies in immunosuppression as well as prevention of infectious diseases and malignancies have also made decisive contributions.

Laparoscopic resection for appendiceal mucocele secondary to endometriosis: A case report.

INTRODUCTION: This case report describes a patient who underwent laparoscopic resection of the mucocele of the appendix secondary to endometriosis, a rarity in clinical practice. PATIENT CONCERNS: The patient was a 38-year-old woman with a history of endometriosis and an ovarian cyst who sought medical advice with a chief complaint of mild right lower abdominal pain. DIAGNOSES: Computed tomography and ultrasonography of the abdomen revealed a cystic lesion at the distal end of the appendix without definitive findings of malignancy. Colonoscopy revealed a submucosal tumor-like elevation at the appendiceal orifice. Appendiceal mucocele was suspected preoperatively. INTERVENTIONS: The lesion was resected laparoscopically. Secondary ileocecal resection with lymphadenectomy was possible if the resected specimen was pathologically diagnosed as a malignant tumor with the risk of lymph node metastasis. OUTCOMES: The resected specimen was pathologically diagnosed as an appendiceal mucocele secondary to endometriosis; therefore, additional surgery was avoided. CONCLUSION: Although appendiceal mucoceles secondary to endometriosis are rare, laparoscopic surgery in which only the lesion was resected is a useful strategy for the treatment and pathological diagnosis of appendiceal mucoceles without findings of malignancy.

Behçet's disease with intestinal involvement: a case report and review of the literature.

BACKGROUND: Behçet's disease (BD) is a chronic systemic disease characterized by vasculitis as the basic pathological change. BD is rare, and gastrointestinal involvement occurs in 3% to 25% of affected patients. This article describes a rare case of intestinal BD along with a literature review of intestinal involvement in BD. CASE PRESENTATION: A 50-year-old Han woman from China presented with a > 6-month history of distending pain in the right upper abdomen. Because of mechanical obstruction secondary to stricture formation from an ileocecal ulcer, she underwent radical right colon resection, and postoperative pathologic examination indicated an ileocecal ulcer. The patient was readmitted to the hospital 6 months postoperatively for recurrence of the same symptoms. Colonoscopy indicated obvious narrowing of the anastomosis with an oval-shaped deep ulcer that could not be passed by the endoscope. Pathologic examination showed acute and chronic inflammation of the anastomotic mucosa and granulation tissue. In addition, gastroscopy showed a 3.0- × 4.0-cm giant ulcer at the junction of the descending bulb along with a sinus tract. Moreover, total gastrointestinal computed tomography angiography showed significant thickening of the intestinal wall near the transverse colon, forming a sinus tract at the junction of the antrum and duodenum with a length of about 1.3 cm and width of about 0.2 cm. Further inquiry regarding the patient's medical history revealed that she had developed repeated oral ulcers 3 years previously and repeated eye inflammation 5 years previously. Specimens of the right half of the colon removed 6 months previously were sent to Run Run Shaw Hospital Affiliated to Zhejiang University for consultation. The pathologic examination revealed vasculitis in the submucosa and subserosa, and the patient was finally diagnosed with BD. She began treatment with adalimumab, and repeat gastroenteroscopy revealed that the intestinal ulcer had significantly improved. CONCLUSIONS: An oval-shaped deep intestinal ulcer is a characteristic lesion in patients with BD and may involve the intestinal muscle layer. This case emphasizes that BD is a vasculitis affecting multiple organs and can present with a single, deep, clean-edged intestinal ulcer that penetrates the bowel wall to form a sinus tract. Therefore, careful examination and differential diagnosis should be carried out to prevent a poor prognosis. Adalimumab is effective for patients with intestinal BD.

Present state of intestinal transplantation in Japan.

INTRODUCTION: Intestinal transplantation (ITx) is the ultimate treatment for intestinal failure (IF). In Japan, most cases of IF are a result of pediatric disease, including secondary or congenital intestinal disease or allied disorders of Hirschsprung's disease. Here, we report the results of the Japanese ITx registry. METHODS: A web-based survey form was completed. We investigated the number, age, sex, indication, surgical procedure, immunosuppressants, postoperative course, and the effects of transplantation in patients who underwent cadaveric or living-donor ITx. RESULTS: By the end of 2022, 42 cases of ITx have been performed in 38 patients in Japan. The donor sources included cadavers (29 cases) and living donors (13 cases). The surgical method was isolated ITx (N = 40) and combined liver and ITx (n = 2). Survival rates were 92%, 73%, and 59% at 1 year, 5 years, and 10 years, respectively. Ninety percent of patients completely discontinued parenteral nutrition. Approximately 80% of the patients had a performance status of 1 or less, indicating that the QOL of patients after ITx was extremely good. CONCLUSION: The results of ITx are acceptable to treat IF patients and the QOL after transplantation is also good.

The evolving role of device-assisted enteroscopy: The state of the art as of August 2023.

Device-assisted enteroscopy (DAE), balloon-assisted enteroscopy (BAE) in particular, has become a routine endoscopic procedure which has revolutionized our approach to small-bowel disease. Evidence demonstrating the efficacy and safety of BAE spans over 22-years of experience, making it an established pillar of minimally invasive care. The robust evidence for BAE's safety and efficacy has now been incorporated into international clinical guidelines, technical reviews, benchmarking performance measures and curricula. The more recently introduced motorized spiral enteroscopy (MSE) which had replaced the previous manual version, abruptly ended its 7-year stint in clinical practice, when it was withdrawn and recalled from the market by its manufacturing company in July 2023, due to several associated serious adverse events (including fatalities). This article, written by the original developer of double-balloon enteroscopy (DBE) and other recognized international experts and pioneers in this field, focuses mainly on the technical aspects, evolving indications, and equipment-related technological advances. Despite the very recent withdrawal of MSE from clinical practice, for completeness, this technology and its technique is still briefly covered here, albeit importantly, along with a short description of reported, associated, serious adverse events which have contributed to its withdrawal/recall from the market and clinical practice.

Pediatric intestine and multivisceral transplant.

PURPOSE OF REVIEW: Intestinal and multivisceral transplantation (ITx, MVTx) is the cornerstone in treatment of irreversible intestinal failure (IF) and complications related to parenteral nutrition. This review aims to highlight the unique aspects of the subject in pediatrics. RECENT FINDINGS: Etiology of intestinal failure (IF) in children shares some similarity with adults but several unique considerations when being evaluated for transplantation will be discussed. Owing to significant advancement in IF management and home parenteral nutrition (PN), indication criteria for pediatric transplantation continues to be updated. Outcomes have continued to improve with current long-term patient and graft survival in multicenter registry reports reported at 66.1% and 48.8% at 5 years, respectively. Pediatric specific surgical challenges such abdominal closure, post transplantation outcomes, and quality of life are discussed in this review. SUMMARY: ITx and MVTx remain lifesaving treatment for many children with IF. However long-term graft function is still a major challenge.

Growing experience of surgical gut rehabilitation: essential role in the management of gut failure in adult patients.

PURPOSE OF REVIEW: With the inherent therapeutic limitations of gut transplantation, the concept of surgical gut rehabilitation was introduced to restore nutritional autonomy in pediatric patients. With favorable outcomes in these young patients, there has been increasing interest in the applicability of gut rehabilitative surgery to a growing population of adults with gut failure due to various etiologies. We aim to review the current status of surgical gut rehabilitation for adult gut failure patients in the era of multidisciplinary gut rehabilitation and transplantation. RECENT FINDINGS: Indications for surgical gut rehabilitation have been gradually expanding, with gut failure after bariatric surgery recently added. Serial transverse enteroplasty (STEP) has been used with favorable outcomes in adult patients, including those with intrinsic intestinal disease. Autologous gut reconstruction (AGR) is the most frequently used surgical rehabilitative method; its outcome is further improved with conjunctive use of bowel lengthening and enterocyte growth factor as a part of comprehensive gut rehabilitation. SUMMARY: Accumulated experiences have validated the efficacy of gut rehabilitation for survival, nutritional autonomy, and quality of life in adults with gut failure of various etiology. Further progress is expected with growing experience around the world.

Nutrition in intestinal transplantation: centre stage or supporting act?

PURPOSE OF REVIEW: Intestinal transplantation (ITx), whether isolated or combined with other organs, is now a valid treatment option in some patients with chronic intestinal failure or extensive venous mesenteric thrombosis. The aim in these patients is not only to restore nutritional autonomy, but also to minimize the risk of complications, both short and long term. Despite parenteral nutrition playing a central part in the management of intestinal failure patients, there are little data about the perioperative and postoperative nutritional management of ITx patients, due to small patient populations per centre. In this review, we collected the scientific data available to date. RECENT FINDINGS: In this review, we will bundle the limited scientific information about diet after intestinal and multivisceral transplantation combined with recommendations from our own clinical practice in 28 ITx patients in University Hospitals Leuven, Belgium. We will discuss the immediate preoperative period, surgical complications necessitating dietary interventions and the late postoperative phase in a stable outpatient transplant recipient. SUMMARY: Although no specific research has been done in the field of ITx, we can extrapolate some findings from other solid organ transplants. Prehabilitation might prove to be of importance; Preserving kidney and liver function in the pretransplant period should be pursued. Transition from parenteral to enteral and oral nutrition can be complex due to inherent surgical procedures and possible complications. Ultimately, the goal is to give patients nutritional autonomy, while also minimizing the risk of foodborne infections by teaching patients well tolerated food practices.

Sexual, urinary, and intestinal dysfunction after rectal surgery: pre-, intra-, and post-operative predictors and trends over time in a single high-volume center.

The incidence of long-term complications after rectal surgery varies widely among studies, and data regarding functional sequelae after transanal surgery are lacking. The aim of this study is to describe the incidence and change over time of sexual, urinary, and intestinal dysfunction in a single-center cohort, identifying independent predictors of dysfunction. A retrospective analysis of all rectal resections performed between March 2016 and March 2020 at our institution was conducted. Validated questionnaires were administered to assess post-operative function. Predictors of dysfunction were assessed by univariate and multivariate analysis. Latent class analysis was used to distinguish different risk profile classes. One hundred and forty-five patients were included. Sexual dysfunction at 1 month rose to 37% for both sexes, whereas urinary dysfunction reached 34% in males only. A significant (p < 0.05) improvement in urogenital function was observed between 1 and 6 months only. Intestinal dysfunction increased at 1 month, with no significant improvement between 1 and 12 months. Independent predictors of genitourinary dysfunction were post-operative urinary retention, pelvic collection, and Clavien-Dindo score ≥ III (p < 0.05). Transanal surgery resulted an independent predictor of better function (p < 0.05). Transanal approach, Clavien-Dindo score ≥ III, and anastomotic stenosis were independent predictors of higher LARS scores (p < 0.05). Maximum dysfunction was found at 1 month after surgery. Improvement was earlier for sexual and urinary dysfunction, whereas intestinal dysfunction improved slower and depended on pelvic floor rehabilitation. Transanal approach was protective for urinary and sexual function, although associated with a higher LARS score. Prevention of anastomosis-related complications resulted protective of post-operative function.

Outcome of laparotomy and conservative treatment of patients with acute mesenteric venous ischemia with viable bowel.

BACKGROUND: Acute mesenteric ischemia (AMI) is one of the most serious abdominal emergencies. Predicting the onset of bowel necrosis that warrants surgical intervention is of paramount importance in AMI. The present study aimed to investigate the outcome of patients with AMI secondary to mesenteric venous occlusion (MVO) and the consequence of non-therapeutic exploratory laparotomy. METHODS: The records of 132 patients with AMI were retrospectively reviewed. The outcome of patients with acute mesenteric venous ischemia (AMVI) and viable bowel was analyzed based on the method of treatment: conservative versus surgical. The impact of non-therapeutic laparotomy on the outcome of patients with AMVI in terms of morbidity, readmission, and mortality was analyzed. RESULTS: Forty-seven patients (34 male) with AMVI had viable bowel. Of the 47 patients with viable bowel, 8 (17%) had an exploratory non-therapeutic laparotomy, whereas 39 patients were treated conservatively. Patients who had non-therapeutic laparotomy had significantly higher complication (50 vs 5.1%, p = 0.005) and readmission rates (37.5 vs 5.1%, p = 0.03) and longer hospital stay (8.5 vs 7 days, p = 0.02) than those treated conservatively. Patients with bowel necrosis who had a therapeutic laparotomy had slightly lower rates of morbidity and mortality as compared to patients with viable bowel who underwent a non-therapeutic laparotomy. CONCLUSION: Careful assessment and informed decision-making in patients with AMVI are crucial to avoid unnecessary surgical intervention that can result in higher rates of complications and readmission and extended hospital stay.

Evisceración vaginal espontánea en paciente con antecedente de histerectomía: reporte de caso y revisión de la literatura / Spontaneous vaginal evisceration in woman with prior pelvic surgery: case report and literature review

Reportar un caso de evisceración vaginal espontánea en paciente con antecedentes quirúrgicos de histerectomía vaginal y hacer una revisión de la literatura sobre los principales factores de riesgo asociados a la presentación de este evento. Se presenta el caso de una paciente de 74 años multípara de 12 partos vaginales con antecedente ginecológico de histerectomía vaginal en 2012, en el año 2014 una sacroespinocolpopexia con colocación de cinta transobturadora más colporrafia anterior, en 2018 presenta cuadro con asas intestinales protruyendo con signos de isquemia a través de defecto en cúpula vaginal, se realiza resección de intestino delgado y anastomosis termino-terminal, con posterior cierre de defecto por vía abdominal. Se realizó una búsqueda en las bases de datos PubMed, Scielo, Google Scholar y Science Direct para artículos publicados en inglés y español, de los últimos 22 años. Se identificaron 16 títulos que cumplieron con los criterios de selección, los resultados de la revisión muestran factores de riesgo comunes. La evisceración vaginal por dehiscencia de la cúpula vaginal es una patología poco prevalente, el abordaje mínimamente invasivo, que ha aumentado en los últimos años, ha conllevado un aumento de la incidencia, siendo la histerectomía por laparoscopia el de mayor riesgo.

To report a case of spontaneous vaginal evisceration in a patient with a surgical history of vaginal hysterectomy, and to review the literature on the main risk factors associated with the presentation of this event. We present the case of a 74-year-old multiparous patient with 12 vaginal deliveries with a gynecological history of vaginal hysterectomy in 2012, in 2014 a sacrospinocolpopexy with placement of transobturator tape plus anterior colporrhaphy, in 2018 she presented with intestinal loops protruding with signs of ischemia through a defect in the vaginal vault, resection of the small intestine and end-to-end anastomosis were performed, with subsequent closure of the defect through the abdomen. A search was made in the PubMed, Scielo, Google Scholar and Science Direct databases for articles published in English and Spanish, from the last 22 years. 16 titles that met the selection criteria were identified; the results of the review show common risk factors. Vaginal evisceration due to dehiscence of the vaginal vault is a rare pathology, the minimally invasive approach, which has increased in recent years, has led to an increase in incidence, with laparoscopic hysterectomy being of greater risk.

[Expert consensus on clinical application management of enteroscopy in children]. / å„¿ç«¥å°è‚ é•œä¸´åºŠåº”ç”¨ç®¡ç†ä¸“å®¶å ±è¯†.

Small bowel disease is one of the difficulties in the diagnosis and treatment of digestive system diseases, and limited examination techniques seriously restrict the diagnosis and treatment level of digestive tract diseases in children. With the wide clinical application of enteroscopy in pediatrics and the optimization of enteroscopy equipment and accessories, enteroscopy technique provides a new method for the diagnosis and treatment of pediatric digestive tract diseases, but there are still many issues and challenges in the standardization of clinical operation and endoscopic treatment. In order to standardize the diagnosis and treatment techniques for enteroscopy in children and improve the diagnosis and treatment level of small bowel disease, the Subspecialty Group of Gastroenterology, the Society of Pediatrics, Chinese Medical Association organized experts to fully discuss and formulate the expert consensus on the clinical application management of enteroscopy in children, with reference to the latest advances in the application of enteroscopy in children.

Long-term bowel dysfunction and decision regret in diverticulitis: A mixed methods study.

BACKGROUND: This study had aimed to describe long-term decision regret, bowel dysfunction, and the overall quality of life in patients with diverticulitis, and to determine if elective colectomy was associated with these patient-reported outcome measures. METHODS: This mixed-methods, survey-based study was administered to a national cohort of patients in the United States with diverticulitis. We measured decision regret (Brehaut Decision Regret), bowel dysfunction (Low Anterior Resection Syndrome score), and the overall quality of life (EuroQol 5 Dimension) in this population. We asked open-ended questions to elucidate factors that influenced patients' choices between elective colectomy and observation. RESULTS: Among the 614 respondents, 294 (48%) chose between colectomy and observational management, 94 (15%) had surgery, and 157 (26%) had major Low Anterior Resection Syndrome. Of the 294 that chose between colectomy and observational management, 51 (17%) experienced decision regret. Colectomy was associated with an average decrease in the Brehaut Decision Regret score by 6 points but was not associated with a categorical measure of decision regret (Brehaut Score ≥50). Bowel dysfunction and overall quality of life were not significantly associated with colectomy. Disease-related factors, psychosocial factors, and interactions with physicians were commonly cited as reasons for pursuing colectomy or observational management. CONCLUSION: Patients with self-reported diverticulitis describe high levels of decision regret and bowel dysfunction regardless of chosen management strategy. Physicians should be aware that psychosocial factors can strongly influence a patient's choice between colectomy and observational management. We advocated for future prospective studies using patient reported outcome metrics to improve outcomes in diverticulitis.