Category Archives: Gastroenterology

Laparoscopic parastomal hernia repair: keyhole, Sugarbaker, sandwich, or hybrid technique with 3D mesh?

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“The most commonly reported approaches for stomal hernia repair include stoma relocation, fascial repair using sutures, and fascial repair using prosthetic mesh with either open or minimally invasive surgery. At present, suture repair for elective surgery is no longer recommended due to high recurrence rates, except in specific circumstances such as
strangulation and contamination of the surgical field, where the use of mesh application should be avoided. In the last decade, many minimally invasive procedures have been
reported in the literature with varying results. In a previous systematic review in 2015, DeAsis et al. investigated the role of laparoscopic surgery in parastomal hernia repair and
concluded that the modified Sugarbaker technique demonstrated superior performance compared to other techniques. Likewise, the sandwich technique showed positive outcomes with low recurrence rates. In another study published in 2015, Szczepkowski et al. described an alternative approach called hybrid with three-dimensional (3D) meshes with promising results.

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Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT)

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“Acute severe gastrointestinal bleeding is a common cause of death worldwide. Bleeding can occur from the upper or lower gastrointestinal tract, but upper gastrointestinal bleeding is more common. The leading causes are peptic ulcer, oesophageal varices, and malignancy. The case fatality rate is approximately 10% for upper gastrointestinal bleeding and 3% for lower gastrointestinal bleeding. Many patients re-bleed after initial haemostasis and those that do have a four times increased risk of death. Patients with acute severe gastrointestinal bleeding usually present with haematemesis or melaena. Patients are often haemodynamically unstable and in need of urgent resuscitation. Acute management
of gastrointestinal bleeding includes blood product transfusion, medical or endoscopic therapy, and surgery.”

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Emory Historical Article: Management of peritoneal carcinomatosis

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“Gastrointestinal malignancies frequently recur with metastatic disease limited to the abdominal cavity. Due to full thickness penetration of tumor through bowel wall and spillage of tumor from lymphatic channels by surgical trauma, tumor cells are disseminated throughout the peritoneal surfaces either prior to at the time of surgical removal of the primary tumor. Diagnosis of recurrent cancer is difficult because no sensitive diagnostic test is available by which to image a small tumor volume present on peritoneal surfaces. Computerized tomography can not demonstrate small to moderate nodules. Intraperitoneal instillation of 131-1 labeled monoclonal antibody has allowed visualization of mucinous tumor on peritoneal surfaces not seen by any other radiologic test. Intraperitoneal chemotherapy has been shown to provide palliation in patients with small volume disease confined to peritoneal surfaces. Because of limited penetration of chemotherapy into large tumor nodules this treatment strategy has not been effective for bulky intraabdominal recurrent cancer. Cytoreductive surgery can make patients relatively disease free. New surgical technologies combined with postoperative intraperitoneal chemotherapy have been shown to be curative for selected patients with recurrent cystadenocarcinoma. The wider application of immediate postoperative intraperitoneal chemotherapy treatments for gastrointestinal patients in an adjuvant setting may be of value in preventing the occurrence of peritoneal carcinomatosis and in improving survival.”

Sugarbaker, P H. “Management of peritoneal carcinomatosis.” Acta medica Austriaca vol. 16,3-4 (1989): 57-60. Request via ILLiad Interlibrary Loan

Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery

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“Acute kidney injury (AKI) is a common complication following major abdominal surgery and is associated with increased length of hospital stay, the progression of chronic kidney disease (CKD), and increased long-term mortality. The rate of AKI amongst patients within different enhanced recovery programs (ERP) is reported to be between 3 and 23%. Patient-related risk factors for AKI include age, comorbidities such as hypertension and diabetes, a history of CKD, and use of angiotensin-converting enzyme inhibitors. Procedure-related factors that may impact on the prevalence of AKI include open surgery, the requirement for blood products, the use of intraoperative vasopressors, and a restrictive perioperative fluid regimen. The original guidelines published by the Enhanced Recovery After Surgery (ERAS) Society for colorectal surgery (CRS) as well as their recent update (2018 guidelines) promote a number of measures which aim to maintain near euvolaemia such as preoperative carbohydrate loading, avoidance of bowel preparation, minimisation of fasting times, minimally invasive surgery, and early resumption of oral fluid therapy.”

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Comparing Outcomes Between “Pull” Versus “Push” Percutaneous Endoscopic Gastrostomy in Acute Care Surgery: Under-Reported Pull Percutaneous Endoscopic Gastrostomy Incidence of Tube Dislodgement

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“Percutaneous endoscopic gastrostomy (PEG) tube placement is a commonly performed procedure in trauma patients.Since the establishment of the acute care surgery (ACS)
model, the role of ACS in PEG tube placement in many institutions has expanded. The incidence of PEG tube complications has been under-reported in the literature and varies
widely among the patient populations studied and the definition of complications utilized. Major and minor complications may range from 3% to 26%. Our institution, under an ACS model, has previously reported an overall 25% complication rate with 10% major and 14% minor complications associated with pull PEG.”

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Six versus three years of adjuvant imatinib in patients with localized GIST at high risk of relapse

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“Gastrointestinal stromal tumor (GIST) is the most common sarcoma and also a paradigmatic model for precision medicine in solid tumors, with the tyrosine kinase inhibitor
imatinib as a standard first-line treatment in the advanced phase and as adjuvant treatment in KIT- or PDGFRA-mutated GIST.”
Whether a longer duration of imatinib treatment improves disease-free survival (DFS) has not been explored in a randomized setting. The randomized IMADGIST study was initiated in 2014 with the aim to determine whether the prolongation of adjuvant imatinib during 3 additional years improves the outcome of high-risk GIST patients versus a standard total duration of 3 years as recommended by clinical practice guidelines. The primary endpoint was DFS. We report here the results of this clinical study.”

Figure 2 Disease-free survival in the in the 3-years and 6-years arms. (A) DFS in the entire series; (B) DFS in the stratification subgroup with a risk of relapse of 35%-70%; (C) DFS in the stratification subgroup with a risk of relapse >70%; (D) DFS in the stratification subgroup with a risk of relapse >70%, with (solid lines) or without (dotted lines) tumor rupture. CI, confidence interval; DFS, disease-free survival; Est, estimate; HR, hazard ratio; KM, Kaplan-Meier.
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Does the use of staple line reinforcement during sleeve gastrectomy and Roux-en-Y gastric bypass affect Clinical Outcomes?

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“The efficacy of bariatric surgery in facilitating sustained weight loss and managing obesity-related comorbidities has been consistently reported in the medical/scientific literature. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are widely accepted bariatric procedures. However, complications, such as gastric leakage, bleeding, stricture, and surgical infection, can lead to significant morbidity and mortality, posing a formidable challenge to bariatric surgeons.
In order to reduce the incidence of complications associated with bariatric surgery, some surgeons have advocated the use of gastric incision staple line reinforcement with the
aim of improving structural integrity and reducing edge tension. However, others have suggested that the reinforcement of the incision edge may compromise suture stability, thereby raising concerns about the overall effectiveness of staple line reinforcement in preventing postoperative complications.”

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