Current progress of source control in the management of intra-abdominal infections.

Intra-abdominal infection (IAI) is a deadly condition in which the outcome is associated with urgent diagnosis, assessment and management, including fluid resuscitation, antibiotic administration while obtaining further laboratory results, attaining precise measurements of hemodynamic status, and pursuing source control. This last item makes abdominal sepsis a unique treatment challenge. Delayed or inadequate source control is an independent predictor of poor outcomes and recognizing source control failure is often difficult or impossible. Further complicating issue in the debate is surrounding the timing, adequacy, and procedures of source control. This review evaluated and summarized the current approach and challenges in IAI management, which are the future research directions.

Extracellular matrix bioink boosts stemness and facilitates transplantation of intestinal organoids as a biosafe Matrigel alternative.

Organoids hold inestimable therapeutic potential in regenerative medicine and are increasingly serving as an in vitro research platform. Still, their expanding applications are critically restricted by the canonical culture matrix and system. Synthesis of a suitable bioink of bioactivity, biosecurity, tunable stiffness, and printability to replace conventional matrices and fabricate customized culture systems remains challenging. Here, we envisaged a novel bioink formulation based on decellularized extracellular matrix (dECM) from porcine small intestinal submucosa for organoids bioprinting, which provides intestinal stem cells (ISCs) with niche-specific ECM content and biomimetic microstructure. Intestinal organoids cultured in the fabricated bioink exhibited robust generation as well as a distinct differentiation pattern and transcriptomic signature. This bioink established a new co-culture system able to study interaction between epithelial homeostasis and submucosal cells and promote organoids maturation after transplantation into the mesentery of immune-deficient NODSCID-gamma (NSG) mice. In summary, the development of such photo-responsive bioink has the potential to replace tumor-derived Matrigel and facilitate the application of organoids in translational medicine and disease modeling.

Guidelines for the diagnosis, treatment, prevention and control of infections caused by carbapenem-resistant gram-negative bacilli.

The dissemination of carbapenem-resistant Gram-negative bacilli (CRGNB) is a global public health issue. CRGNB isolates are usually extensively drug-resistant or pandrug-resistant, resulting in limited antimicrobial treatment options and high mortality. A multidisciplinary guideline development group covering clinical infectious diseases, clinical microbiology, clinical pharmacology, infection control, and guideline methodology experts jointly developed the present clinical practice guidelines based on best available scientific evidence to address the clinical issues regarding laboratory testing, antimicrobial therapy, and prevention of CRGNB infections. This guideline focuses on carbapenem-resistant Enterobacteriales (CRE), carbapenem-resistant Acinetobacter baumannii (CRAB), and carbapenem-resistant Pseudomonas aeruginosa (CRPA). Sixteen clinical questions were proposed from the perspective of current clinical practice and translated into research questions using PICO (population, intervention, comparator, and outcomes) format to collect and synthesize relevant evidence to inform corresponding recommendations. The grading of recommendations, assessment, development and evaluation (GRADE) approach was used to evaluate the quality of evidence, benefit and risk profile of corresponding interventions and formulate recommendations or suggestions. Evidence extracted from systematic reviews and randomized controlled trials (RCTs) was considered preferentially for treatment-related clinical questions. Observational studies, non-controlled studies, and expert opinions were considered as supplementary evidence in the absence of RCTs. The strength of recommendations was classified as strong or conditional (weak). The evidence informing recommendations derives from studies worldwide, while the implementation suggestions combined the Chinese experience. The target audience of this guideline is clinician and related professionals involved in management of infectious diseases.

[Outcomes of chronic radiation intestinal injury treated with surgical interventions].

OBJECTIVE: To explore the surgical approaches and clinical outcomes of chronic radiation intestinal injury (CRII). METHODS: From January 1, 2001 to December 31, 2010, at Department of Surgery, Nanjing General Hospital of Nanjing Command a consecutive series of 206 CRII patients undergoing surgical interventions was reviewed retrospectively. There were 64 males and 142 females with an age range of (50 ± 11) years old. The indications, surgical approaches, surgical complications and mortality were analyzed. RESULTS: 206 CRII patients received 229 surgical treatment, 31 patients underwent two or more operations. The course of surgical interventions included intestinal obstruction (n = 142), intestinal fistula (n = 56), proctitis (n = 12), bleeding (n = 6) and others (n = 13). They underwent 229 laparotomies including intestinal resection and primary anastomosis (n = 142), intestinal resection and enterostomy (n = 57), exclusion of radiation-related gastrointestinal diseases (n = 14) and other procedures (n = 16). The occurrence rate of postoperative intestinal complications was 25.7% (53/206). Five patients (2.4%) died within the postoperative 28 days. CONCLUSION: Surgery is often required for patients with chronic radiation-induced intestinal obstruction, fistula, hemorrhage and perforation, etc. Resection and primary anastomosis with undamaged segments may be performed safely in selected patients. And a judicious use of stoma can reduce the rates of major surgical mortality and morbidity.

Intensive versus conventional insulin therapy in type 2 diabetes patients undergoing D2 gastrectomy for gastric cancer: a randomized controlled trial.

BACKGROUND: This study was to compare the effect of intensive insulin therapy (IIT) to conventional insulin therapy (CIT) on postoperative outcomes among type 2 diabetes mellitus (DM) patients who underwent D2 gastrectomy for gastric cancer. METHODS: We randomly assigned gastric cancer patients with type 2 DM who underwent radical gastrectomy to receive IIT (maintenance of blood glucose at a level between 4.4 and 6.1 mmol/l) with insulin infusion or CIT (maintenance of blood glucose at a level between 10 and 11.1 mmol/l) during the postoperative period. RESULTS: Of the 179 eligible patients, 92 patients were assigned to receive IIT and 87 patients to receive CIT. Mean blood glucose concentrations were lower in the intensive group (IG) than in the conventional group (CG) (5.5 ± 0.8 vs. 9.9 ± 1.0 mmol/l, P < 0.001). Hypoglycemia occurred in 6 patients (6.5%) in the IG (P = 0.029) versus in 1 patient (1.1%) in the CG. Hospital mortality did not differ significantly between two groups (4.3% vs. 5.7%, P = 0.742). However, IIT significantly reduced morbidity (from 18.4 to 7.6%, P = 0.031). Also, IIT shortened the days to suture removal, postoperative hospital stay, and postoperative duration of antibiotic use. The HOMA-IR score was lower at all time points in IG. Moreover, IIT increased the postoperative HLA-DR expression on monocytes on postoperative days 3 and 5. CONCLUSIONS: IIT significantly reduced short-term morbidity but not mortality among type 2 DM patients who underwent D2 gastrectomy for gastric cancer. Furthermore, a possible mechanism of suppression of the insulin resistance and improvement of HLA-DR expression may partially explain the benefits of IIT.

[Open abdomen management treatment of liver injury in rats with abdominal compartment syndrome and sepsis].

OBJECTIVE: To evaluate the open and closed management treatment of liver injury in rats with sepsis and abdominal compartment syndrome (ACS). METHODS: The sepsis and ACS rats (n = 72) were randomized divided into two groups. One group used closed management (n = 36), the other accepted the open abdomen management (n = 36). The rats were killed at 1, 6 h, 1, 3, 5, 7 d after operation. Blood was collected for liver function tests. Liver sections assessed pathologically and the expressions of Toll-like receptor 4 (TLR4), tumor necrosis factor (TNF)-α, interleukin (IL)-6, signal transducers actuators of transcription (STAT3) and suppressor of cytokine signaling 3 (SOCS3) of rat livers were examined by RT-PCR. RESULTS: The early stage after operation, TNF-α and IL-6 concentrations, STAT3 expressions in rat liver were higher in open abdomen rats than the closed management ones (P < 0.05). TLR4 and SOCS3 expressions were lower in open abdomen rats than the closed management ones (P < 0.05). Aspartate aminotransferase, alanine aminotransferase levels also was lower in open abdomen ones (P < 0.05). CONCLUSIONS: The randomized study demonstrates that open abdomen management could improve liver regeneration in the early stage after operation. Also open abdomen could reduce inflammatory response by reducing TLR4 expressions.

Current knowledge on the multiform reconstitution of intestinal stem cell niche.

The development of "mini-guts" organoid originates from the identification of Lgr5+ intestinal stem cells (ISCs) and circumambient signalings within their specific niche at the crypt bottom. These in vitro self-renewing "mini-guts", also named enteroids or colonoids, undergo perpetual proliferation and regulated differentiation, which results in a high-performance, self-assembling and physiological organoid platform in diverse areas of intestinal research and therapy. The triumphant reconstitution of ISC niche in vitro also relies on Matrigel, a heterogeneous sarcoma extract. Despite the promising prospect of organoids research, their expanding applications are hampered by the canonical culture pattern, which reveals limitations such as inaccessible lumen, confine scale, batch to batch variation and low reproducibility. The tumor-origin of Matrigel also raises biosafety concerns in clinical treatment. However, the convergence of breakthroughs in cellular biology and bioengineering contribute to multiform reconstitution of the ISC niche. Herein, we review the recent advances in the microfabrication of intestinal organoids on hydrogel systems.

[Protein loss in critically ill patients during continuous veno-venous hemofiltration].

OBJECTIVE: To evaluate protein loss in critically ill patients with acute renal failure during continuous veno-venous hemofiltration (CVVH) and analysis the major factor impacting protein clearance. METHODS: A analysis was carried out in eighteen (twelve male and six female) sepsis or severe acute pancreatitis patients with acute renal failure from September 2008 to September 2009. The average age was 45 years (39 - 62 years). CVVH was conducted for 24 h in all patients. Effluent volume, blood speed, ultrafiltration rate and transmembrane pressure (TMP) were 4000 ml/h, (277 ± 89) ml/h, (179 ± 4) ml/min and (173 ± 48) mm Hg (1 mm Hg = 0.133 kPa) respectively. Blood samples were collected before and after filtration in order to detect protein concentration. Ultrafiltrate was obtained hourly to measure protein concentration and calculate protein loss during session. RESULTS: Mean protein concentration was (231 ± 67) mg/L and protein loss was (22 ± 6) g/d in ultrafiltrate samples. The difference in serum protein level during hemofiltration was not significant [(56 ± 6) g/L vs. (55 ± 10) g/L, P > 0.05], while there was a weak, but statistically significant correlation between the ultrafiltrate protein concentration and the corresponding value for serum protein (r = 0.481, P < 0.05). However, there was a strong and statistically significant correlation between the ultrafiltrate protein concentration and the TMP (r = 0.564, P < 0.01). Stepwise multiple regression analysis showed that TMP and serum protein concentration played a pivotal role in ultrafiltrate protein loss. CONCLUSIONS: In addition to renal replacement therapy, serum protein would be cleared through hemofilter during CVVH. TMP and serum protein concentration are the main factors that affect protein loss in ultrafiltrate. As a result, it is necessary to take account of the protein loss in ultrafiltrate when setting nutritional schedule.

[The application progress of fluid de-escalation therapy in abdominal infection-induced septic shock].

After adequate fluid resuscitation in the early stage of septic shock, excessive accumulation of fluid in the body leads to organ dysfunction, which prolongs hospitalization, mechanical ventilation time, and renal replacement therapy time, and is associated with poor prognosis. The fluid de-escalation therapy is an important fluid management strategy performed in the late stage of septic shock. It aims to clear excess fluid by restricting fluid infusion, using diuretics and renal replacement therapy to achieve a negative fluid balance. The fluid de-escalation therapy contributes to improve clinical outcome of septic shock patients and reduce the mortality. This review mainly discusses the current researches and application progress of the fluid de-escalation therapy of abdominal infection-induced septic shock through clarifying its origin, time and endpoint, method of the therapy, the relationship with the control of the source of abdominal infection and its impact on organ function and clinical outcome. Our study intends to provide guidance for the treatment of abdominal infection-induced septic shock in the late stage, and explore the novel research directions.

[Predictive value of lung ultrasound score on weaning outcome in patients with intro-abdominal infection undergoing mechanical ventilation].

OBJECTIVE: To evaluate the value of lung ultrasound score (LUS) on predicting weaning outcome in patients with intro-abdominal infection (IAI) undergoing mechanical ventilation. METHODS: Patients with IAI undergoing mechanical ventilation admitted to Research Institute of General Surgery of East War Zone Hospital and intensive care unit (ICU) of the First People's Hospital of Lianyungang from January to December in 2018 were included. The patients who satisfied weaning criteria were enrolled in the weaning process, which included spontaneous breathing trial (SBT) and extubation. They were divided into SBT success group and SBT failure group according to whether passed 120-minute SBT or not. LUS scores before and after SBT were compared between the two groups. The patients in the SBT success group were extubated, and they were divided into successful extubation group and failed extubation group for sub-group analysis according to whether re-intubation was needed in 48 hours after extubation. LUS score before extubation (at the end of SBT) and 48 hours after extubation (48 hours after extubation in the successful extubation group or before re-intubation in the failed extubation group) were compared. The receiver operating characteristic (ROC) curve was drawn to evaluate the predictive value of LUS score before SBT for SBT failure and LUS score before extubation for the failure. RESULTS: A total of 76 patients with IAI undergoing mechanical ventilation were included. Twenty-three patients had duration of mechanical ventilation less than 48 hours, severe chronic obstructive pulmonary disease (COPD), tracheotomy or automatic discharge were excluded, and 53 patients were enrolled. SBT was failed in 9 patients, and successfully performed in 44 patients, of whom 23 patients with successful extubation, and 21 with failed extubation. The LUS scores before and after SBT in the SBT failure group were significantly higher than those in the SBT success group (before SBT: 13.22±1.99 vs. 10.79±1.64, t = -3.911, P = 0.000; after SBT: 19.00±1.12 vs. 13.41±1.86, t = -8.665, P = 0.000). ROC curve analysis showed that the area under ROC curve (AUC) of LUS score before SBT for predicting SBT failure was 0.82 [95% confidence interval (95%CI) was 0.67-0.98, P = 0.002]. When the optimum cut-off value was 12.5, the sensitivity was 66.7%, and the specificity was 84.1%. Sub-group analysis showed that the LUS scores before and after extubation in the failed extubation group were significantly higher than those in the successful extubation group (before extubation: 14.19±1.60 vs. 12.69±1.81, t = -2.881, P = 0.006; after extubation: 16.42±1.59 vs. 12.78±1.54, t = -7.710, P = 0.000). ROC curve analysis showed that the AUC of LUS score before extubation for predicting the failure was 0.81 (95%CI was 0.69-0.92, P = 0.000). When the optimum cut-off value was 13.5, the sensitivity was 80.0%, and the specificity was 65.2%. CONCLUSIONS: LUS score can effectively predict SBT outcome, risk of re-intubation after extubation in patients with IAI undergoing mechanical ventilation.

Nutritional Management of Patients With Enterocutaneous Fistulas: Practice and Progression.

The management of enterocutaneous fistulas (ECF) can be challenging because of massive fluid loss, which can lead to electrolyte imbalance, severe dehydration, malnutrition and sepsis. Nutritional support plays a key role in the management and successful closure of ECF. The principle of nutritional support for patients with ECF should be giving enteral nutrition (EN) priority, supplemented by parenteral nutrition if necessary. Although total parenteral nutrition (TPN) may be indicated, use of enteral feeding should be advocated as early as possible if patients are tolerant to it, which can protect gut mucosal barrier and prevent bacterial translocation. A variety of methods of enteral nutrition have been developed such as fistuloclysis and relay perfusion. ECF can also be occluded by special devices and then EN can be implemented, including fibrin glue application, Over-The-Scope Clip placement and three-dimensional (3D)-printed patient-personalized fistula stent implantation. However, those above should not be conducted in acute fistulas, because tissues are edematous and perforation could easily occur.

Application of a 3D-printed "fistula stent" in plugging enteroatmospheric fistula with open abdomen: A case report.

BACKGROUND: Open abdomen (OA) has been generally accepted for its magnificent superiority and effectiveness in patients with severe trauma, severe intra-abdominal infection, and abdominal compartment syndrome. In the meantime, OA calls for a mass of nursing and the subsequent enteroatomospheric fistula (EAF), which is one of the most common complications of OA therapy, remains a thorny challenge. CASE SUMMARY: Our team applied thermoplastic polyurethane as a befitting material for producing a 3D-printed "fistula stent" in the management of an EAF patient, who was initially admitted to local hospital because of abdominal pain and distension and diagnosed with bowel obstruction. After a series of operations and OA therapy, the patient developed an EAF. CONCLUSION: Application of this novel "fistula stent" resulted in a drastic reduction in the amount of lost enteric effluent and greatly accelerated rehabilitation processes.

Effects of recombinant human growth hormone on enterocutaneous fistula patients.

AIM: To explore the effects of recombinant human growth hormone (rhGH) on intestinal mucosal epithelial cell proliferation and nutritional status in patients with enterocutaneous fistula. METHODS: Eight patients with enterocutaneous fistulas received recombinant human growth hormone (10 microg/d) for 7 d. Image analysis and immunohistochemical techniques were used to analyse the expression of proliferating cell nuclear antigen (PCNA) in intestinal mucosal epithelial cells in biopsy samples from the patients who had undergone an endoscopic biopsy through the fistula at day 0, 4 and 7. Body weights, nitrogen excretion, serum levels of total proteins, albumin, prealbumin, transferrin and fibronectin were measured at day 0, 4 and 7. RESULTS: Significant improvements occurred in the expression of PCNA in the intestinal mucosal epithelial cells at day 4 and 7 compared to day 0 (24.93 +/- 3.41%, 30.46 +/- 5.24% vs 12.92 +/- 4.20%, P < 0.01). These changes were accompanied by the significant improvement of villus height (500.54 +/- 53.79 microm, 459.03 +/- 88.98 microm vs 210.94 +/- 49.16 microm, P < 0.01), serum levels of total proteins (70.52 +/- 5.13 g/L, 74.89 +/- 5.16 g/L vs 63.51 +/- 2.47 g/L, P < 0.01), albumin (39.44 +/- 1.18 g/L, 42.39 +/- 1.68 g/L vs 35.74 +/- 1.75 g/L, P < 0.01) and fibronectin (236.3 +/- 16.5 mg/L, 275.8 +/- 16.9 mg/L vs 172.5 +/- 21.4 mg/L, P < 0.01) at day 4 and 7, and prealbumin (286.38 +/- 65.61 mg/L vs 180.88 +/- 48.28 mg/L, P < 0.05), transferrin (2.61 +/- 0.12 g/L vs 2.41 +/- 0.14 g/L, P < 0.05) at day 7. Nitrogen excretion was significantly decreased at day 7 (3.40 +/- 1.65 g/d vs 7.25 +/- 3.92 g/d, P < 0.05). No change was observed in the body weight. CONCLUSION: Recombinant human growth hormone could promote intestinal mucosal epithelial cell proliferation and protein synthesis in patients with enterocutaneous fistula.

Impaired Coagulation Status in the Crohn's Disease Patients Complicated with Intestinal Fistula.

BACKGROUND: Intestinal fistula is one of the common complications of Crohn's disease (CD) that might require surgical treatment. The clinical characteristics and outcomes of CD with intestinal fistula are much different from CD alone. This study was to investigate whether the coagulation status of CD is changed by intestinal fistula. METHODS: Data were retrospectively analyzed for 190 patients with a definitive diagnosis of CD who were registered at the Jinling Hospital between January 2014 and September 2015. Baseline clinical characteristics and laboratory indices of initial admission and 7 days after intestinal fistula resections were collected. Student's t-test and the Wilcoxon rank-sum test were used to compare differences between the two groups. RESULTS: Compared with CD patients without intestinal fistula, prothrombin time (PT) in patients with intestinal fistula was significantly longer (12.13 ± 1.27 s vs. 13.18 ± 1.51 s, P < 0.001 in overall cohort; 11.56 ± 1.21 s vs. 12.61 ± 0.73 s, P = 0.001 in females; and 12.51 ± 1.17 s vs. 13.37 ± 1.66 s, P = 0.003 in males). Platelet (PLT) count was much lower in intestinal fistula group than in nonintestinal fistula group (262.53 ± 94.36 × 109/L vs. 310.36 ± 131.91 × 109/L, P = 0.009). Multivariate logistic regression showed that intestinal fistula was significantly associated with a prolonged PT (odds ratio [OR] = 1.900, P < 0.001), a reduced amount of PLT (OR = 0.996, P = 0.024), and an increased operation history (OR = 5.408, P < 0.001). Among 65 CD patients receiving intestinal fistula resections, PT was obviously shorter after operation than baseline (12.28 ± 1.16 s vs. 13.02 ± 1.64 s, P = 0.006). CONCLUSIONS: Intestinal fistula was significantly associated with impaired coagulation status in patients complicated with CD. Coagulation status could be improved after intestinal fistula resections.

[Enteral nutrition support in 21 patients after opening abdomen].

OBJECTIVE: To evaluate the feasibility and efficacy of enteral nutrition (EN) in patients underwent open-abdomen managements. METHODS: Twenty-one patients who received at least 3 days of EN after opening the peritoneal cavity between January 2003 and November 2006 were included in this study. Energy expenditure and actual caloric and protein intake were determined in some patients. The levels of serum protein and nitrogen balance before and after the EN were analyzed. Other related complications were also evaluated. RESULTS: Average daily total caloric intake was 93% - 95% of estimated needs. The EN support was administered (8.8 +/- 5.5) d after opening the abdominal cavity and lasted for (51.5 +/- 33.6) d. Initial serum protein levels were low and below normal but increased in all of the patients after the EN. The average nitrogen balance was (-28.6 +/- 5.4) g/d. Diarrhea, gastric reflux, vomiting and abdominal distention occurred in 67%, 23%, 9.5% and 23% of the patients, respectively. All the complications were managed well. CONCLUSIONS: EN support could be effectively and safely given in patients requiring opening peritoneal cavity management.

[Susceptibility genes and serum markers of intestinal fibrosis in Crohn disease].

Crohn disease (CD) is a chronic inflammatory disease which progressively affects the digestive tract with unknown etiology. During the disease course, intestinal fibrosis will gradually develop in many CD patients and results in irreversible fibrosis stricture, causing refractory abdominal pain and even intestinal obstruction, and necessitating one or more surgical interventions. Thus far the exact etiology of CD remains unknown. It is believed that genetic, environmental and immunologic factors are involved, which may also predict the development of intestinal fibrosis. Recent studies have found the association of mutations in genes, such as NOD2, ATG16L1, CX3CR1, IL-23R and MMP3 with the fibrogenic phenotype of CD. In addition, serum extracellular matrix molecules, growth factors, miRNAs and microbial antibodies have also been linked to the fibrogenesis in CD patients, however the results of researches were divergent. Therefore it is of significance to explore noninvasive markers of intestinal fibrosis with high sensitivity and specificity, and the high-throughput proteomic technique may be an approach that deserves further investigation. Screening the high-risk patients for the fibrostenotic phenotype of CD by susceptibility genes, and early detection of intestinal fibrosis using noninvasive serum markers, will help improve the treatment outcomes and reduce the surgical rates. The article aims at summarizing the current susceptibility genes and serum markers of intestinal fibrosis in CD.

[Effect of postoperative hyperglycemia on clinical outcome of gastrointestinal fistula patients undergoing gastrointestinal reconstruction].

OBJECTIVE: To investigate the effect of hyperglycemia within postoperative 48 hours on gastrointestinal (GI) fistula patients without preoperative diagnosis of diabetes undergoing selective GI reconstruction. METHODS: Clinical data of GI fistula patients with age of 18 to 70 years and without diffuse peritonitis and systemic infection undergoing definitive GI reconstruction at Intestinal Fistula Center of Jinling Hospital from September 2012 to December 2015 were retrospectively analyzed. According to the highest blood glucose (BG) value detected within postoperative 48 hours, patients were divided into normoglycemia (BG<6.9 mmol/L), mild hyperglycemia (6.9 to 11.4 mmol/L) and severe hyperglycemia (BG≥11.5 mmol/L) groups. Clinical manifestations were compared among three groups. Effects of postoperative hyperglycemia on associated parameters, including postoperative surgical site infection, anastomotic leakage, intestinal nutrition recovery, hospital stay and hospitalization cost were investigated. RESULTS: A total of 314 patients were enrolled, of whom postoperative gastric fistula occurred in 6 cases, small intestinal fistula in 95 cases, ileocolonic anastomotic fistula in 116, and colorectal fistula in 97 cases. One hundred and ninety-three (61.5%) patients experienced hyperglycemia, including 148 cases of mild hyperglycemia group and 45 cases of severe hyperglycemia group, the other 121 cases were of normoglycemia group. There were no significant differences in gender, BMI, ratio of smoking, ratio of alcohol user and primary diseases among 3 groups (all P>0.05). Older patients were vulnerable to postoperative hyperglycemia and patients who developed hyperglycemia were also prone to have increased ASA score (all P=0.000). Hyperglycemia patients had significantly higher ratio of postoperative ileocolonic anastomotic fistula (mild hyperglycemia group: 40.5%, 60/148; severe hyperglycemia group: 44.4%, 20/45) than normoglycemia cases (29.8%,36/121). Compared to normoglycemia group, ratio of intra-operative transfusion case was higher (P=0.001), operative time was longer (P=0.026), ratio of number of anastomosis >2 was higher (P=0.001), ratio of receiving laparoscopic-assisted operation was lower (P=0.005), ratio of postoperative surgical site infection was higher (P=0.006), incidence of anastomotic leakage was higher (P=0.004), ratio of re-operation was higher (P=0.004), intestinal nutrition recovery time was longer (P=0.001), ICU stay was longer (P=0.001), total hospitalization time was longer (P=0.000) and hospitalization cost was more expensive (P=0.000) in both two hyperglycemia groups. Multivariate regression analysis showed that mild hyperglycemia and severe hyperglycemia were independent risk factors to predict surgical site infection (OR=1.99, 95%CI: 1.12 to 3.54, P=0.019; OR=3.02, 95%CI: 1.36 to 6.70, P=0.007) and anastomotic leakage (OR=7.59, 95%CI: 1.68 to 34.34, P=0.009; OR=13.4, 95%CI: 2.50 to 71.65, P=0.002). Multivariate linear regression analysis indicated that intestinal recovery time of normoglycemia group was 2 days shorter and 3 days shorter, and hospitalization time of normoglycemia group was 2 days shorter and 10 days shorter as compared with mild hyperglycemia and severe hyperglycemia group, respectively. CONCLUSIONS: Elevated postoperative BG is common in GI fistula patients receiving selective GI reconstruction. Postoperative hyperglycemia is significantly associated with surgical site infection, anastomotic leakage and prolonged intestinal recovery. BG control treatment should be recommended for those patients with postoperative hyperglycemia.

3D-printed "fistula stent" designed for management of enterocutaneous fistula: An advanced strategy.

Enterocutaneous fistulas (ECFs) are great challenges during the open abdomen. The loss of digestive juice, water-electrolyte imbalance and malnutrition are intractable issues during management of ECF. Techniques such as "fistula patch" and vacuum-assisted closure therapy have been applied to prevent contamination of open abdominal wounds by intestinal fistula drainage. However, failures are encountered due to high-output fistula and anatomical complexity. Here, we report 3D-printed patient-personalized fistula stent for ECF treatment based on 3D reconstruction of the fistula image. Subsequent follow-up demonstrated that this stent was well-implanted and effective to reduce the volume of enteric fistula effluent.

Enteral refeeding syndrome after long-term total parenteral nutrition.

BACKGROUND: Early enteral feeding (EF) may result in fever, elevated white blood cell count, increased serum levels of liver enzymes, and diarrhea. We name the complications "enteral refeeding syndrome", as a subtype of refeeding syndrome, because they are likely to result from long-term lack of lumen nutrition. The aim of this study was to investigate the characteristics of enteral refeeding syndrome after long-term total parenteral nutrition (TPN), and the solution for the disease. METHODS: We collected the clinical data of 100 patients with gastrointestinal fistula, who were cured from Apirl 2001 to July 2002. Their fasting time, daily stool frequency, body temperature, heart rate, respiratory rate, levels of transaminases, alkaline phosphatase (AKP), and gamma-glutamylcyclotransferase (gamma-GT), white blood cell count, and systemic inflammatory reaction syndrome (SIRS) score were recorded before and 1, 3, 5, 10, and 15 days after EF. Student's t test and analysis of variance were used to analyze the data. RESULTS: Of the 100 patients, 56 were cured after selective resection of intestinal fistula, 15 were cured by emergency operation, and 29 recovered spontaneously. The levels of AKP and gamma-GT increased significantly on the 3rd day after EF [On the 3rd day after EF, (243.0 +/- 121.6) U/L and (177.2 +/- 109.9) U/L vs. before EF (181.5 +/- 127.5) U/L and (118.4 +/- 94.2) U/L, P < 0.05], and decreased gradually afterwards. The SIRS scores on the 1st day (1.05 +/- 1.08) and 3rd day (0.96 +/- 1.11) after EF were significantly higher than that before EF (0.72 +/- 0.84), then decreased to 0.83 +/- 0.91, 0.49 +/- 0.73 and 0.32 +/- 0.60 on the 5th, 10th and 15th days after EF. The number of patients with diarrhea at 1, 3, 5, 10 and 15 days post-EF were 31, 26, 12, 13, and 7, respectively. CONCLUSIONS: The longer the TPN lasts, the more severe the enteral refeeding syndrome becomes. Continuous EF is effective for the syndrome. Early enteral nutrition is useful in preventing it.

[Surgical management of chronic radiation enteritis].

OBJECTIVE: To explore the surgical methods and the clinical results of chronic radiation enteritis. METHODS: Treatments were applied to forty-nine cases of chronic radiation enteritis complicated with intestinal obstruction, enterocutaneous fistula, intestinal stenosis, intestinal bleeding, severe proctocolitis and intestinal perforation, among whom 47 cases received an average of 2.8 +/- 2.1 operations. Twenty-six cases received resection of the injured segment with primary anastomosis, fourteen cases received intestinal resection and proximal enterostomy, among whom 6 ostomies were permanent, and another 8 cases received secondary ostomy closure. The injured intestinal segments were spared in 7 cases. RESULTS: Forty-seven among 49 cases were cured (success rate, 96%) with no anastomotic leakage. Two patients died. CONCLUSIONS: Surgical complications of chronic radiation enteritis should be managed operatively. The operative method should be chosen according to the general condition of the patients and the complexity of the abdomen. Perioperative management and proper selection of intestinal segments for anastomosis are essential for the success.