Postoperative infectious complications have a negative oncological impact in patients after stent placement with malignant large bowel obstruction.

PURPOSE: In this study, we aimed to investigate the oncological impact of postoperative infection in patients with malignant large bowel obstruction managed by self-expandable metallic stent placement as a bridge to surgery. METHODS: The cohort of this multicenter retrospective study comprised 129 patients with pathological stage II/III malignant large bowel obstruction who had undergone bridge to surgery. Patients were allocated to no-postoperative infection (n = 116) and postoperative infection groups (n = 13). RESULTS: The postoperative infection group had a significantly greater proportion of men, fewer harvested lymph nodes, and longer postoperative hospital stays than did the no-postoperative infection group. Self-expandable metallic stent-related variables, including clinical failure, were not associated with postoperative infection. Male sex and low body mass index were identified as risk factors for postoperative infection by multivariate logistic regression. Three-year relapse-free survival rates were 75.5% and 30.8% in the no-postoperative infection and postoperative infection groups, respectively; this difference is statistically significant. Male sex, postoperative infection, and T4 were identified as independent prognostic factors by multivariate Cox proportional hazard analysis. The postoperative infection group had a significantly higher total recurrence rate and shorter interval to recurrence than did the no-postoperative infection group. CONCLUSION: To the best of our knowledge, this is the first study to show that postoperative infection in bridge to surgery patients has a negative oncological impact. This finding indicates that further improvement in perioperative management of bridge to surgery patients is required to minimize postoperative infection and that patient-risk stratification and additional therapy would contribute to improving oncological outcomes.

Outcome of self-expandable metal stents placement for obstructive colorectal cancer: 7 years' experience from a Swedish tertiary center.

BACKGROUND AND STUDY AIMS: Self expandable metal stents (SEMS) is an alternative to emergency surgery to treat malignant large bowel obstruction. It can be used either for palliation or as a bridge to curative surgery. Our study aims to review the outcomes of SEMS treatment in a tertiary center and to find predictors for the clinical outcome. PATIENT AND METHODS: We retrospectively analyzed data from SEMS insertion at Sahlgrenska University Hospital, a referral center in Western Sweden (1.7 million inhabitants), between 2014 and 2020. Data collected were age, the intent of intervention, tumor localization, complication rate, technical and clinical success, 30- and 90-days mortality as well as long-term survival for the indication bridge to surgery. RESULTS: We identified 265 SEMS insertions (mean age 72, female 49.4%). Most SEMS were used for palliation (90.2%). The malign obstruction was most often located in the left colon (71.7%). Technical success was achieved in 259 (97.7%) cases and clinical success in 244 (92.1%) cases. Post-operative complications occurred in 11 cases (4.2%). The 30-days mortality rate was 11.7% and the 90-day was 31.7%. In our analysis the tumor site was not associated with adverse outcomes and bridge to surgery indication was a positive prognostic factor for the 90-day mortality. CONCLUSIONS: We found that SEMS is an effective and safe treatment for patients with acute obstructive colorectal cancer.

Impact of endoscopic metallic stent placement and emergency surgery on detection of viable circulating tumor cells for acute malignant left-sided colonic obstruction.

BACKGROUND: Self-expanding metal stents (SEMS) served as a bridge to surgery (BTS). However, this method may be associated with worse long-term prognosis and relapse of CRC patients. Therefore, we attempted to clarify this in the angle of circulating tumor cells (CTCs). METHODS: A multicenter study was performed from March 2018 to January 2021. Thirty-two colorectal cancer patients with obstruction were selected, of which 21 patients were performed SEMS as a BTS while 11 patients were performed emergency surgery. Bloods samples were collected in two groups of patients for further detecting CTCs. In the SEMS group, the samples were collected before and after stent insert and after radical surgery performed. In the ES group, the samples were collected before stent insert and after emergency surgery performed. RESULTS: The number of CTCs did not show statistically significant differences before and after stent placement (34.90 vs 38.33, p=0.90), neither between the SEMS group and ES group in initial CTC levels (34.90 vs 58.09, p=0.394). No significant differences (38.33 vs 58.09, p=0.632) were observed after stent insert in the SMES group and the initial CTC levels in the ES group. Moreover, no major differences (24.17 vs 42.27, p=0.225) were observed after radical operation performed in both groups. CONCLUSION: The treatment of SEMS does not cause an increase in the number of CTC after stent insertion. Furthermore, there are may be other factors besides CTC to cause these poorer oncologic outcomes after SEMS placement.

Management of Malignant Bowel Obstruction: An Innovative Proactive Outpatient Nurse-Led Model of Care for Patients With Advanced Gynecologic Cancer.

BACKGROUND: Malignant bowel obstruction (MBO) in patients with advanced gynecologic cancer (GyCa) can negatively impact clinical outcomes and quality of life. Oncology nurses can support these patients with adequate tools/processes. PROBLEM: Patients with GyCa with/at risk of MBO endure frequent emergency or hospital admissions, impacting patient care. APPROACH: Optimizing oncology nurses' role to improve care for patients with GyCa with/at risk of MBO, the gynecology oncology interprofessional team collaborated to develop a proactive outpatient nurse-led MBO model of care (MOC). OUTCOMES: The MBO MOC involves a risk-based algorithm engaging interdisciplinary care, utilizing standardized tools, risk-based assessment, management, and education for patients and nurses. The MOC has improved patient-reported confidence level of bowel self-management and decreased hospitalization. Following education, nurses demonstrated increased knowledge in MBO management. CONCLUSIONS: An outpatient nurse-led MBO MOC can improve patient care and may be extended to other cancer centers, fostering collaboration and best practice.

Relapse of melanoma presenting as jejunal intussusception.

Melanoma is a relatively rare tumour with tendency to metastasize to the gastrointestinal tract. Metastasis to the intestine constitutes a majority of the gastrointestinal tract melanoma metastases and confers a poor prognosis. While post-mortem studies detect that more than half of the melanoma patients have gastrointestinal tract metastasis, only minority are diagnosed, and even rarer present with intussusception. Intussusception, mainly a paediatric entity, is also seen among adult patients with underlying inflammatory bowel disease or tumour. In this report, we describe a patient with a melanoma in remission who presented with intestinal obstruction after months of vague abdominal complaints. Laparotomy revealed jejunal intussusception and histopathological staining confirmed the melanoma diagnosis. No other distant metastases other than the jejunum were revealed after extensive investigation.

International consensus to standardise histopathological scoring for small bowel strictures in Crohn's disease.

OBJECTIVE: Effective medical therapy and validated trial outcomes are lacking for small bowel Crohn's disease (CD) strictures. Histopathology of surgically resected specimens is the gold standard for correlation with imaging techniques. However, no validated histopathological scoring systems are currently available for small bowel stricturing disease. We convened an expert panel to evaluate the appropriateness of histopathology scoring systems and items generated based on panel opinion. DESIGN: Modified RAND/University of California Los Angeles methodology was used to determine the appropriateness of 313 candidate items related to assessment of CD small bowel strictures. RESULTS: In this exercise, diagnosis of naïve and anastomotic strictures required increased bowel wall thickness, decreased luminal diameter or internal circumference, and fibrosis of the submucosa. Specific definitions for stricture features and technical sampling parameters were also identified. Histopathologically, a stricture was defined as increased thickness of all layers of the bowel wall, fibrosis of the submucosa and bowel wall, and muscularisation of the submucosa. Active mucosal inflammatory disease was defined as neutrophilic inflammation in the lamina propria and any crypt or intact surface epithelium, erosion, ulcer and fistula. Chronic mucosal inflammatory disease was defined as crypt architectural distortion and loss, pyloric gland metaplasia, Paneth cell hyperplasia, basal lymphoplasmacytosis, plasmacytosis and fibrosis, or prominent lymphoid aggregates at the mucosa/submucosa interface. None of the scoring systems used to assess CD strictures were considered appropriate for clinical trials. CONCLUSION: Standardised assessment of gross pathology and histopathology of CD small bowel strictures will improve clinical trial efficiency and aid drug development.

Constrictive and Hypertrophic Strictures in Ileal Crohn's Disease.

BACKGROUND & AIMS: Strictures in Crohn's disease (CD) are classically attributed to fibromuscular hypertrophy of the intestinal wall. We have identified and characterized CD-related ileal strictures that result instead from mural constriction (ie, reduced external circumference). METHODS: Twenty-four strictures and internal controls from 17 adults with obstructive CD were analyzed by cross-sectional morphometry. RESULTS: The stricture-to-control circumference ratios (CRs) ranged from 0.53 to 1.7. Six strictures with CR ≥1.0, designated hypertrophic, had concentrically thickened walls, mean 3-fold increases in cross-sectional area and stainable fibromucular tissue, and high transmural inflammation scores. In contrast, 18 strictures with CR <1.0, designated constrictive, had thin, pliant walls, cross-sectional areas and stainable fibromuscular tissue comparable with control values, and low transmural inflammation scores. Eight mildly constrictive strictures also showed mild fibromuscular mural expansion that fell short of statistical significance. Twelve of 18 constrictive strictures (67%) occurred multiply (2-4 strictures per specimen) in contrast with hypertrophic strictures, all of which occurred singly (P = .01). Constriction correlated quantitatively with circumferential serosal fat wrapping (P = .003) and was associated with myenteric lymphocytic plexitis (P = .02). Disease duration was shortest among subjects with constrictive strictures and correlated with increasing circumference (CR ≤0.8, 6.3 ± 6.2 years; CR >0.8, 8.7 ± 6.4 years; and CR ≥1.00, 13.7 ± 5.0 years, respectively; P = .03). CONCLUSIONS: Constrictive ileal strictures in CD differ pathologically and clinically from hypertrophic strictures, featuring little or no fibromuscular mural expansion, frequent multiplicity, and earlier onset. Mesenteric fat wrapping and myenteric plexitis may contribute to their pathogenesis. Pathologic manifestations of constriction and hypertrophy can coexist, suggesting that stricture heterogeneity may be shaped in part by the dynamics of constrictive and hypertrophic processes.

Safety and feasibility of neoadjuvant chemotherapy as a surgical bridge for acute left-sided malignant colorectal obstruction: a retrospective study.

BACKGROUND: For colorectal cancer, preoperative (neoadjuvant) chemotherapy is more effective than postoperative chemotherapy because it not only eradicates micrometastases more effectively but also reduces the risk of incomplete intraoperative resection and tumor cell shedding. For the treatment of acute left-sided malignant colorectal obstruction, colorectal stents as well as stoma are being used to relieve the obstructive colorectal cancer, and as a bridge to surgery, allowing easy mobilization and resection of the colon. Neoadjuvant chemotherapy combined with self-expandable metal stents (SEMS) or neoadjuvant chemotherapy combined with decompressing stoma (DS) can be used as a bridge to elective surgery (BTS) as an alternative to emergency surgery in patients with acute left-sided malignant colorectal obstruction, but its benefit is uncertain. The purpose of this study was to evaluate the safety and feasibility of neoadjuvant chemotherapy as a bridge to surgery in the treatment of acute left-sided malignant colorectal obstruction. METHODS: Data from patients who were admitted with acute left-sided malignant colorectal obstruction between January 2012 and December 2020 were retrospectively reviewed, and patients with gastrointestinal perforation or peritonitis were excluded. We performed one-to-two propensity score matching to compare the stoma requirement, postoperative complications, and other short-term oncological outcomes between the neoadjuvant chemotherapy group and surgery group. RESULTS: There were no differences in intraoperative blood loss, operative time, one-year postoperative mortality, and postoperative tumor markers between the two groups. The 1-year recurrence-free survival (RFS) rates of neoadjuvant chemotherapy group and surgery group were 96.8 and 91.3% (p = 0.562). The neoadjuvant chemotherapy group was able to reduce stoma rate 1 year after surgery (p = 0.047). Besides, the neoadjuvant group significantly reduced postoperative bowel function time (p < 0.001), postoperative hospital stay (p < 0.001), total hospital stay (p = 0.002), postoperative complications (p = 0.017), reduction in need to stay in the intensive care unit (ICU) (p = 0.042). CONCLUSIONS: Neoadjuvant chemotherapy as a bridge to elective surgery in patients with acute left-sided malignant colorectal obstruction is safe and has many advantages. Prospective multicenter studies with large samples are needed to further evaluate the feasibility of neoadjuvant chemotherapy.

Colonic stenting as a bridge to surgery for obstructive colon cancer: is it safe in the long term?

BACKGROUND: The placement of a self-expanding metal stent in patients with obstructive colon cancer is used as a bridge to surgery. However, due to a lack of consensus and insufficient data, the long-term oncologic outcomes after colonic SEMS placement remain unclear. We assessed the long-term oncologic outcomes and adverse effects of colonic stenting for malignant colonic obstruction. METHODS: We included 198 patients admitted to Korea University Anam Hospital between 2006 and 2014 for obstructive colon cancer, of whom 98 underwent SEMS placement as a bridge to surgery and 100 underwent direct surgery without stenting. The clinicopathologic characteristics, overall survival, and disease-free survival were compared. RESULTS: There were no significant differences in long-term oncologic outcomes between the two groups. The median follow-up durations were 61.55 and 58.64 months in the SEMS and DS groups, respectively. There were also no significant differences in the 5-year OS (77.4% vs. 74.2%, p = 0.691) and 5-year DFS (61.7% vs. 71.0%, p = 0.194) rates between the groups. However, the DS group had significantly more early postoperative complications (p = 0.002). CONCLUSIONS: Colonic SEMS deployment as a bridge to surgery did not negatively affect long-term oncologic outcomes when compared with DS. In addition, colonic stenting decreased early postoperative complications and reduced the time for patients to return to normal daily activities.

Differences in clinical outcomes according to the time interval between the bridge to surgery stenting and surgery for left-sided malignant colorectal obstruction.

BACKGROUND: Self-expandable metal stent (SEMS) placement is commonly used as a bridge to surgery (BTS) for left-sided malignant colorectal obstruction (MCO). However, the optimal time interval between BTS stenting and surgery for left-sided MCO is unclear, and the results of previous studies are conflicting. This study aimed to determine the differences in clinical outcomes according to the time interval between BTS stenting and surgery in left-sided MCO. METHODS: Data from 594 patients who underwent SEMS placement for MCO between January 2009 and December 2018 were reviewed. Among them, 148 patients who underwent SEMS placement as BTS treatment and curative surgery were enrolled. The enrolled patients were divided into three groups according to the interval between BTS stenting and surgery: group 1 (interval ≤2 weeks), group 2 (interval 2-3 weeks), and group 3 (interval >3 weeks). RESULTS: Group 2 and 3 patients underwent significantly higher rates of laparoscopic surgery than those in group 1 (83.7, 81.0 vs. 53.2 %, respectively; P=0.003, P=0.003, respectively). Also, rates of stoma formation directly after resection were significantly higher in group 1 compared to groups 2 and 3 (21.3 vs 2.3, 6.9%, respectively; P=0.008, P=0.043, respectively). Bridging interval had no effect on SEMS-related complications, resection-related complications, 90-day mortality, permanent stoma formation, 3-year disease-free survival, and 3-year overall survival. CONCLUSIONS: A bridging interval of > 2 weeks between BTS stenting and surgery for left-sided MCO is preferable for lower stoma formation rates and higher rates of laparoscopic approach operation, with no difference in short-term and long-term outcomes including complication, mortality, and survival.

Efficacy of drug and endoscopic treatment of Crohn's disease strictures: A systematic review.

BACKGROUND AND AIMS: Strictures are the commonest complication in Crohn's disease. Surgery and endoscopic dilation are the mainstays of treatment, while drug therapy has often been considered contraindicated. The benefit of nonsurgical treatments, particularly drug and endoscopic therapy, need to be defined. METHODS: Ovid MEDLINE, Embase, Emcare, PsycINFO, CINAHL and the Cochrane Library (inception until August 30, 2019) were searched. Studies with ≥ 10 patients with Crohn's disease strictures, reporting on outcomes following medication or endoscopic treatment, were included. RESULTS: Of 3480 records, 85 studies met inclusion criteria and formed the basis of this analysis. Twenty-five studies assessed drug therapy; none were randomized trials. Despite study heterogeneity anti-tumor necrosis factor (TNF) therapy appeared effective, with 50% of patients avoiding surgery after 4 years of follow up. No other drug therapy was of demonstrable benefit. Sixty studies assessed endoscopic therapy including 56 on endoscopic balloon dilation, two assessed needle knife stricturotomy, and two stent insertion. Dilation was equally effective for de novo and anastomotic strictures ≤ 5 cm in length, with most studies reporting a subsequent surgical rate of 30% to 50%. Repeat dilation was required in approximately half of all patients. CONCLUSIONS: Anti-TNF drug therapy and endoscopic balloon dilation are effective strategies for avoiding surgery in patients with stricturing Crohn's disease. Additional endoscopic therapies require further evaluation. Early data suggest that combining these therapies may provide greater benefit than individual therapies. Optimization of current drug and endoscopic therapy, and the incorporation of newer therapies, are needed for stricturing Crohn's disease.

Predictors of Abnormal Functional Luminal Impedance Planimetry Findings in Non-mechanical Esophagogastric Junction Outflow Obstruction.

BACKGROUND: Esophagogastric junction outflow obstruction (EGJOO) is a common but nonspecific motility pattern identified by esophageal high-resolution manometry (HRM). Functional luminal impedance planimetry (FLIP) provides information regarding lower esophageal sphincter (LES) mechanics, which can identify achalasia spectrum disorders and is useful in evaluating EGJOO. However, the relationship between HRM and FLIP parameters in EGJOO is not clearly defined. AIMS: To identify predictors of abnormal FLIP findings in patients with non-mechanical EGJOO. METHODS: This is a retrospective cohort study of patients with non-mechanical EGJOO who underwent FLIP between 10/1/16 and 7/1/19. Demographic data including age and gender, examination indication, concomitant medications, HRM parameters, symptom burden, and FLIP metrics of diameter and distensibility index (DI) were collected. DI was categorized as not low (DI > 2.8), borderline low (DI 1.1-2.8), and definitely low (DI ≤ 1). Kruskal-Wallis and Fisher's exact tests were used to assess the relationship between HRM and FLIP parameters and to identify predictors of abnormal FLIP. RESULTS: Among the 44 patients studied, most were female (n = 33, 75%) and the median age was 63. The median IRP was 18.2, and 10 (23%) patients used chronic narcotics. Lower total heartburn and regurgitation scores, and LES diameter by FLIP are associated with definitely low DI. CONCLUSIONS: In patients with non-mechanical EGJOO, reflux burden scores and FLIP diameters can aid in predicting DI. These results may provide useful adjunctive data to help in differentiating which patients have meaningful outflow obstruction.

Supernumerary Remnant Vas Deferens Like Wolffian-Derivatives in a Young Child With Abdominal Cocoon Syndrome-A Clinicopathological Novelty.

The abdominal cocoon syndrome is a rare cause of recurring intestinal obstruction in children. It refers to encasement of the small bowel by a fibrocollagenous membrane forming a cocoon. We report a nine year old male presenting with abdominal pain, distension, bilious vomiting and inability to pass stool and flatus for two days. In view of a persistently increasing bilious nasogastric output, an urgent exploratory laparotomy was performed. The small bowel loops were matted together forming a cocoon densely adherent to the parietal peritoneum with supra-colic fibrous bands. The bands histologically displayed multiple ductal remnants with epithelium resembling that of ductus deferens. These structures showed immunopositivity for pan-cytokeratin and basal CD10.Workup for tuberculosis and other etiological causes was unremarkable. This is the first documented case of abdominal cocoon in a pediatric subject associated with supernumerary wolffian remnants.

[New approaches in conservative treatment of acute adhesive small bowel obstruction]. / Novye podkhody v konservativnom lechenii ostroi spaechnoi tonkokishechnoi neprokhodimosti.

OBJECTIVE: To improve the outcomes of therapy of acute adhesive small bowel obstruction via development of a comprehensive management including CT, deep endoscopy-assisted nasointestinal drainage of small bowel with injection of a water-soluble contrast. MATERIAL AND METHODS: There were 128 patients with acute adhesive small bowel obstruction for the period from 2015 to 2018. The study included 2 groups of patients depending on therapeutic approach and duration of treatment. In the first group, conventional approach for acute adhesive small bowel obstruction was applied. Upon admission, all patients with confirmed acute adhesive small bowel obstruction underwent gastric intubation for decompression of the upper gastrointestinal tract. Barium sulfate injection followed by X-ray examination was performed to assess an effectiveness of therapy. In the second group, computed tomography was performed in addition to X-ray examination and ultrasound. Moreover, conservative treatment included deep endoscopy-assisted nasointestinal drainage and subsequent administration of a water-soluble contrast in addition to traditional approaches. RESULTS: Therapy was effective in 99 (71.2%) patients; 39 (28.8%) ones required surgery. Deep endoscopy-assisted nasointestinal drainage with injection of a water-soluble contrast was effective in 45 (78.9%) patients. Overall mortality in traditional approach was 1.4%, postoperative mortality - 3.7%. There were no lethal outcomes in case of a new approach. CONCLUSION: Deep endoscopy-assisted nasointestinal drainage with injection of a water-soluble contrast is the most effective therapeutic method for acute adhesive small bowel obstruction (78.9%). These findings can significantly improve treatment outcomes in these patients.

[Timing of surgery, intestinal ischemia and other real factors of mortality in acute adhesive small bowel obstruction: a multiple-center study]. / Faktory riska letal'nogo iskhoda pri ostroi spaechnoi tonkokishechnoi neprokhodimosti. Rezul'taty mnogotsentrovogo issledovaniya.

OBJECTIVE: To analyze the factors of mortality in patients with acute adhesive small bowel obstruction (ASBO). MATERIAL AND METHODS: A retrospective multiple-center study included 143 (85.6%) patients with ASBO out of 167 consecutive patients with small bowel obstruction for the period 2017-2019. All patients were divided into 3 groups: early surgery group (within 12 hours after admission), late surgery (after 12 hours), non-surgical management group. The outcomes and Kaplan-Meier survival were compared in all groups. RESULTS: ASBO was resolved without surgery in 77 (53.8%) patients 19.6±17.4 (M=14) hours. In the Early Surgery Group (n=36), 24 patients had strangulation, 12 ones had non-strangulated bowel obstruction. In the Late Surgery Group (n=30), 15 patients had strangulation and 15 ones had no strangulation. Mortality was similar in early and late surgery (p=0.287), early and late surgery in patients with strangulation (p=0.940), early and late surgery in patients without strangulation (p=0.76). Patients died (n=10) after surgery only. Thus, postoperative mortality was 15.2%, overall mortality - 7.0%. All patients who underwent surgery after 24 hours (n=14) survived. Surgery increased the mortality risk compared to non-surgical management (95% CI 0 - 15.9, p=0.001). There was no effect of surgery time (more or less than 12 hours) on mortality for strangulation (95% CI 13.0-16.7, p 0.788) and non-strangulated obstruction (95% CI 29.4-5.4, p=0.061), bowel resection (95% CI 33.3-14.0, p=0.187), presence of bowel ischemia (95% CI 14.3-17.9, p 0.613). CONCLUSION: Delayed surgery may be advisable in patients with ASBO and no obvious signs of strangulation due to less mortality.

Adhesive Small Bowel Obstruction: Predictive Radiology to Improve Patient Management.

Adhesive small bowel obstruction (SBO) remains one of the leading causes of emergency room visits and is still associated with high morbidity and mortality rates. Because the management of adhesive SBO has shifted from immediate surgery to nonoperative treatment in the absence of ischemia, it is crucial to rapidly detect or predict strangulation, which requires emergent surgery. CT is now established as the best imaging technique for the initial assessment of patients suspected of having adhesive SBO. CT helps confirm the diagnosis of mechanical SBO, locate the site of obstruction, establish the cause, and detect complications. This article is a review of the role of imaging in answering specific questions to help predict the management needs of each individual patient. It includes (a) an update on the best CT signs for predicting ischemia and a need for bowel resection; (b) a discussion of the CT features that help differentiate open-loop from closed-loop obstruction and a single adhesive band from matted adhesions and how these differences can influence the management; and (c) a review of the main CT predictors of the success or failure of nonoperative management in adhesive SBO.

Health-related quality of life in patients with inoperable malignant bowel obstruction: secondary outcome from a double-blind, parallel, placebo-controlled randomised trial of octreotide.

BACKGROUND: This analysis aims to evaluate health-related quality of life (HrQoL) (primary outcome for this analysis), nausea and vomiting, and pain in patients with inoperable malignant bowel obstruction (IMBO) due to cancer or its treatments randomised to standardised therapies plus octreotide or placebo over a maximum of 72 h in a double-blind clinical trial. METHODS: Adults with IMBO and vomiting recruited through 12 services spanning inpatient, consultative and community settings in Australia were randomised to subcutaneous octreotide infusion or saline. HrQoL was measured at baseline and treatment cessation (EORTC QLQ-C15-PAL). Mean within-group paired differences between baseline and post-treatment scores were analysed using Wilcoxon Signed Rank test and between group differences estimated using linear mixed models, adjusted for baseline score, sex, age, time, and study arm. RESULTS: One hundred six of the 112 randomised participants were included in the analysis (n = 52 octreotide, n = 54 placebo); 6 participants were excluded due to major protocol violations. Mean baseline HrQoL scores were low (octreotide 22.1, 95% CI 14.3, 29.9; placebo 31.5, 95% CI 22.3, 40.7). There was no statistically significant within-group improvement in the mean HrQoL scores in the octreotide (p = 0.21) or placebo groups (p = 0.78), although both groups reported reductions in mean nausea and vomiting (octreotide p < 0.01; placebo p = 0.02) and pain scores (octreotide p < 0.01; placebo p = 0.03). Although no statistically significant difference in changes in HrQoL scores between octreotide and placebo were seen, an adequately powered study is required to fully assess any differences in HrQoL scores. CONCLUSION: The HrQoL of patients with IMBO and vomiting is poor. Further research to formally evaluate the effects of standard therapies for IMBO is therefore warranted. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12608000211369 (date registered 18/04/2008).

Peritoneal Carcinomatosis in Gastro-Entero-Pancreatic Neuroendocrine Neoplasms: Clinical Impact and Effectiveness of the Available Therapeutic Options.

BACKGROUND: Peritoneal carcinomatosis (PC) can affect the quality of life of patients with gastro-entero-pancreatic neuroendocrine neoplasms (GEP-NENs). Peritoneal disease control by medical therapies in these patients has been poorly investigated Objectives: To describe, in a consecutive series of GEP-NENs, the clinical impact of PC and to report the effectiveness of available treatments in PC control. METHODS: A retrospective, monocenter analysis was performed of 135 GEP-NENs (1993-2016) with at least a 12-month follow-up. Peritoneal disease progression was defined as detection of a significant increase in size or appearance of new implants by imaging. RESULTS: A total of 62.9% of cases had diffuse PC (involving at least 2 abdominal quadrants). According to WHO 2017 classification, cases were 42.3% neuroendocrine tumors NET-G1, 45.5% NET-G2, 6.5% NET-G3, 4.9% neuroendocrine carcinomas NEC-G3, and 0.8% mixed neuroendocrine-nonneuroendocrine neoplasms. Bowel obstruction occurred in 30 (22.2%) patients mainly depending on size of peritoneal implants (HR: 1.10; 95% CI: 1.02-1.20; p = 0.01). Patients with diffuse PC treated with peptide receptor radionuclide therapy (PRRT) showed peritoneal progression in 37.5% of cases, and bowel obstruction or ascites in 28.1%. Better peritoneal disease control was observed in cases receiving somatostatin analogs at first-line therapy, probably due to a less aggressive disease behavior for these patients. CONCLUSIONS: Bowel obstruction is not uncommon in GEP-NENs with PC. PRRT should be adopted with caution in GEP-NENs with diffuse PC, but larger series are needed to confirm these data.

Experimental Models of Partial Intestinal Obstruction in Young Mice: Establishment, and Evaluation.

BACKGROUND: Partial small bowel obstruction (SBO) is a common, potentially hazardous, surgical entity caused by numerous factors in humans. A number of techniques have been reported as efficient to simulate partial SBO in murine models. However, there is little data concerning their long-term survival. Our study presents a novel technique and evaluates its long-term efficiency compared with other commonly used techniques. MATERIALS AND METHODS: Sixty C57BL/6 mice aged 6 to 8 wk were randomly divided into five intervention groups: ligation, intestinal ring, partial ligation, microclips, and the novel triple suture technique. The ring groups were subdivided into narrow, medium, and wide ring and partial ligation groups were subdivided at 1/3, 1/2, and 2/3 of the lumen. Survival cutoff time was set at 4 wk. Animals were then euthanized and small bowel muscle layer thickness was histopathologically evaluated. RESULTS: None of the animals of the ligation and the ring groups reached the cutoff survival time. The mortality rate of the partial ligation and the microclips groups at the 4-week period were 33.3% and 0%, respectively. However, elimination of the performed intervention was revealed at the time of euthanasia and no alterations of the muscle layer were revealed at histopathology. The "triple suture" group had a survival rate of 90% until euthanasia and the sutures were apparent in all cases. Macroscopic evaluation showed small to mild proximal lumen dilatation in 6 of 10 animals. Histopathological evaluation of the specimens confirmed the partial obstruction. CONCLUSIONS: The "triple suture" technique is a new, robust, reliable, and inexpensive technique for experimental long-standing partial SBO, with very low mortality.

An internal hernia caused by Meckel's diverticulum: a case report.

BACKGROUND: Meckel's diverticulum is a remnant of the omphalomesenteric duct. It can lead to intestinal perforation, obstruction and gastrointestinal bleeding. While the internal hernia caused by Meckel's diverticulum is rarely reported. CASE PRESENTATION: We report a case of a 45-year old female patient who presented with intestinal obstruction and on laparotomy was found to have Meckel's diverticulum with internal hernia causing intestinal gangrene. Segmental bowel resection was performed and the patient had uneventful recovery. CONCLUSIONS: In patients with acute intestinal obstruction without previous abdominal surgery, Meckel's diverticulum and its complications should be suspected.