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Objective To investigate the clinical efficacy of laparoscopic surgery for pelvic radiation induced enteritis (PRIE).Methods The retrospective cross-sectional study was conducted The clinical data of 66 patients with PRIE who were admitted to the Nanjing General Hospital of Nanjing Military Command from January 2012 to December 2015 were collected.Laparoscopic surgery will be applied to patients based on patients' clinical manifestations after completing relative examinations.Observation indicators:(1) surgical situations:surgical method,conversion to open surgery,reoperation,surgical incision length,grade of abdominal adhesions,surgical time,volume of intraoperative blood loss,duration of postoperative hospital stay;(2) occurrence of surgical complications;(3) follow-up situations.Follow-up using telephone interview was performed to detect patients' survival and recurrence of PRIE up to April 2016.Measurement data with normal distribution were represented as x±s.Results (1) Surgical situations:① of 59 patients with small intestinal obstruction,11underwent laparoscopic small intestinal resection or enterostomy,including 2 with conversion to open surgery due to dense adhesions,1 due to uncertainty of tumor recurrence and 1 due to intestinal canal dilatation affected vision;48 underwent laparoscopic resection of ileocecum,including 1 1 with conversion to open surgery due to dense adhesions,2 due to iliac vessels injury and 4 due to injuries of sigmoid colon,rectum and bladder.Four patients with colonic obstruction and proctitis underwent laparoscopic colostomy,without conversion to open surgery.One patient received conversional open surgery and underwent intestinal resection of internal fistula + exclusion of rectal stump due to intestine-rectum fistula induced dense adhesions.One patient with anal atresia underwent laparoscope-assisted resection of pelvic tissues and rectal stump.One patient with localized peritonitis underwent laparoscope-assisted ileostomy.② Among 66 patients,4 received reoperations,including 2 with cervical cancer and 2 with rectal cancer,reoperations of 4 patients were respectively caused by intestine-rectum fistula,rectovaginal fistula,anastomotic fistula and ostomy + stoma reversion.Of 4 patients with reoperations,1 received conversion to open surgery due to dense adhesions and then underwent intestinal resection of internal fistula+exclusion of rectal stump,1 with rectovaginal fistula underwent laparoscopic colostomy,1 with anastomotic fistula underwent resection and anastomosis of small intestine due to dense adhesions and 1 underwent laparoscopic ileostomy and stoma reversion.③ Sixty-six patients received 70 operations,including 46 laparoscopic surgeries and 24 conversion to open surgeries.Surgical incision length and average length were respectively 3.0-6.0 cm,4.0 cm in 46 laparoscopic surgeries and 8.0-25.0 cm,15.5 cm in 24 conversion to open surgeries.Grade 0,1,2 and 3 of abdominal adhesions were detected respectively in 7,13,13,13 laparoscopic surgeries and in 1,1,12,10 conversion to open surgeries.Operation time,volume of intraoperative blood loss and duration of postoperative hospital stay were respectively (128±50) minutes,(108±56) mL,(30± 15)days in 46 laparoscopic surgeries and (173±44) minutes,(222± 105) mL,(38± 19) days in 24 conversion to open surgeries.(2) Occurrence of surgical complications:1 patient was complicated with bladder injury in 46 laparoscopic surgeries,and 2,4 and 2 patients in 24 conversion to open surgeries were respectively complicated with bladder injury,colorectal injury and injury of right iliac vessels,they received intraoperative symptomatic treatment.Two,3,3,6 and 1 patients were respectively complicated with pleural effusion,wound infection or dehiscence,venous catheter infection,anastomotic fistula and cholestatic cholecystitis after 46 laparoscopic surgeries.One,5,1,4,2 and 1 were respectively complicated with pleural effusion,wound infection or dehiscence,venous catheter infection,anastomotic fistula,cholestatic cholecystitis and abdominal wall hemorrhage after 24 conversion to open surgeries.They were improved by symptomatic treatment.(3) Follow-up situations:all the 66 patients were followed up for 4-50 months,with a median time of 26 months.During the follow-up,3 patients died of intraperitoneal infection,short bowel syndrome and pulmonary infection,and 3 patients had PRIE.Conclusion The appropriate surgical method is selected based on clinical manifestations of patients,and laparoscopic surgery is safe and feasible for PRIE.
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Objective To investigate the effect of acellular dermal matrix (ADM) for abdominal closure to prevent abdominal high pressure after intestinal transplantation.Method ADM was used for abdominal closure following intestinal transplantation in a 17-year-old man with ultra-short bowel syndrome.Two ADMs with 12 cm 20 cm were reconstituted intraoperatively with warm sterile normal saline.After flattened under peritoneum,the ADM was pruned and then sewn to the muscular layer of abdominal wall by interrupted transfixing suture with absorbable suture.A negative pressure drainage tube was placed over an area of native fascia in the subcutaneous space.Skin and soft tissues were closed by interrupted suture.Result The intra-abdominal pressure was not higher than 7 cmH2O 90 h post-operation.The ventilator has been withdrawn 18 h after operation.Enternal nutrition was given from postoperative day 6.He required surgical exploration for abdominal abscess on the postoperative day 19.The ADM closely adhered to the abdominal wall and no abscess in abdomen was related to ADM.Conclusion ADM can be safely used for abdominal closure and effectively prevent intraabdominal high pressure in this intestinal transplantation.No infection or graft loss occurred in the early postoperative period.More observations are needed to study the long-term results and complications in the future.
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Since its introduction as an alternative intestinal microbiota alteration approach, fecal microbiota transplantation (FMT) has been increasingly used as a treatment of choice for patients with ulcerative colitis (UC), but no reports exist regarding FMT via percutaneous endoscopic cecostomy (PEC). This report describes the case of a 24-year-old man with a 7-year history of recurrent, steroid-dependent UC. He received FMT via PEC once per day for 1 month in the hospital. After the remission of gastrointestinal symptoms, he was discharged from the hospital and continued FMT via PEC twice per week for 3 months at home. The frequency of stools decreased, and the characteristics of stools improved soon thereafter. Enteral nutrition was regained after 1 week, and an oral diet was begun 1 month later. Two months after the FMT end point, the patient resumed a normal diet, with formed soft stools once per day. The follow-up colonoscopy showed normal mucus membranes; then, the PEC set was removed. On the subsequent 12 months follow-up, the patient resumed orthobiosis without any gastrointestinal discomfort and returned to work. This case emphasizes that FMT via PEC can not only induce remission but also shorten the duration of hospitalization and reduce the medical costs; therefore, this approach should be considered an alternative option for patients with UC.
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Humans , Young Adult , Cecostomy , Colitis, Ulcerative , Colonoscopy , Diet , Enteral Nutrition , Fecal Microbiota Transplantation , Follow-Up Studies , Gastrointestinal Microbiome , Hospitalization , Membranes , Mucus , UlcerABSTRACT
Objective Cytomegalovirus (CMV) has remained the most significant pathogen that threatens the outcome of small bowel transplantation (SBTx). This paper To outline preliminary experience of prophylaxis and treatment of cytomegalovirus (CMV) in 15 cases subject to small bowel transplantation (SBTx) and also review current progress of diagnosis and treatment of CMV.Methods Fifteen cases of SBTx were divided into 3 eras: era Ⅰ (1994-1995)-3 SBTx treated with cyclosporine-based immunosuppression; era Ⅱ (2003-2006)-7 SBTx treated with tacrolimus-based immunosuppression; and era Ⅲ (2007-present)-5 SBTx treated with Alemtuzumab induction therapy and maintenance tacrolimus monotherapy. No antiviral prophylaxis after SBTx was applied during era Ⅰ; in era Ⅱ, ileoscopic and pathological diagnosis of CMV graft enteritis was defined, and plasma diagnosis tools including CMV-IgM, CMV pp65 and CMV DNA with PCR were introduced. 2-3 weeks intravenous ganciclovir prophylaxis of CMV was underway, followed by 3 months oral acyclovir; In era Ⅲ, more precise real-time PCR technique was used to detect CMV DNA copies, and the schedule of the CMV surveillance was set up, antiviral prophylaxis therapy was modified to 2-3 weeks intravenous ganciclovir and 3 months oral ganciclovir, and preemptive therapy to halt the progression of asymptomatic infection to clinical disease was also introduced.Results Two of 15 SBTx recipients suffered from CMV with the occurrence rate of 13.3%. One recipient in era Ⅱ suffered from CMV graft enteritis on postoperative day 45, and CMV pneumonia on postoperative day 64, he received intravenous ganciclovir and thymus peptide, paused tacrolimus maintenance, and finally he died from severe acute cellular rejection. 94 100 copies/ml of CMV DNA in periphery blood of a recipient in era Ⅲ was detected with real-time PCR at 3rd month after SBTx, and a preemptive therapy successfully halted the CMV infection.Conclusion Antiviral prophylaxis therapy and close surveillance of CMV infection after SBTx should be performed, and preemptive therapy can also halt the CMV infection. When CMV disease occurs, the recipient should receive effective antiviral therapy, and acute cellular rejection also should be closely monitored at same time.
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Objective To evaluate the efficiency of monitoring parameters and methods of immunosuppresive treatment in intestinal transplantation and to provide scientific evidence for establishment of Intestinal Transplant Registry.Methods The data of 15 patients receiving intestinal transplantation between 1994 and 2009 were analyzed retrospectively for one year. The patients were fallen into 3 eras (1994-1995, 2003-2006, 2007-2009) according to different immunosuppresive strategies. The perioperative status and one-year survival rate were followed up. The monitoring frequency of implications of intestinal transplantation, such as rejection, infection, toxic and side-effects, was evaluated. The monitoring parameters were examined in the proportion of lymphocytes, concentration of tacrolimus, and function of the liver and kidney during a follow-up period of one year.Results During 1994-1995 and 2003-2006, the survival time of grafts was under one year. During 2007-2009, the 6-month and one-year survival rate in 5 patients (grafts) was 100% and 83.33% respectively; The increased frequency of rejection occurred during 7 to 12 months after operation; The closure of abdominal stoma was postponed from postoperative six months to one year; Asymptomatic mild rejection after operation was examined (10/13, 76.92%).Conclusion During one year postoperation, monitoring methods, parameters and frequency for immunosuppressive treatment in intestinal transplantation are rational, and may monitor the disease conditions of the patients.
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Objective To summarize the timing and diagnostic value of endoscopic biopsy of intestinal graft after small bowel transplantation (SBTx).Methods Fifteen cases of SBTx were divided into 3 eras:era Ⅰ (1994-1995)-3 cases of SBTx treated with cyclosporine-based immunosuppression; era Ⅱ (2003-2006)-7 cases of SBTx treated with tacrolimus-based immunosuppression,and era Ⅲ (2007-present) than CVC group 5 cases of SBTx treated with Atemtuzumab induction therapy and maintenance tacrolimus monotherapy.The scheme of endoscopic surveillance was initially used in era Ⅲ, the first endoscopic biopsy was performed on postoperative day 3,2 times weekly during the first month, followed once weekly during months 2-3, once every other week during months 4-6 and once monthly thereafter.When clinical signs and symptoms of rejection were present, and during rejection episodes, the additional endoscopic biopsies were also performed.Results A total of 276 biopsies of these 15 SBTx recipients were obtained.Fifty-one biopsies (18.5%) were diagnosed as acute cellular rejection (ACR), which included IND to mild (n = 32,11.6 %), moderate (n = 9,3.3 %), and severe (n = 1 0, 3.6 %), two biopsies (0.7 %) were diagnosed as cytomegalovirus (CMV) enteritis and other 2 biopsies (0.7 %) bacteria enteritis.The ACR episodes verified by biopsy pathology and undergoing anti-rejection treatment were 20 (11 IND to mild,5 moderate,and 4 severe) ,and 1 episode of CMV enteritis and 1 episode of bacteria enteritis were observed.Conclusion Endoscopic surveillance and biopsy pathology is crucial diagnostic tool for ACR and sepsis.ACR surveillance after SBTx and early diagnosis of ACR could be made with scheming endoscopic biopsies.Endoscopic biopsy can be used to make differential diagnosis when clinical signs and symptoms were present, and to guide the treatment during anti-rejection episode.
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Objective Invasive fungal infection (IFI) after small bowel transplantation (SBTx) is aggressive and associated with high mortality rates. This paper reviewed preliminary experience of treatment of IFI in 15 cases after SBTx. Methods Fifteen cases of SBTx were divided into 3 groups according to the eras. era Ⅰ (1994-1995)-3 cases of SBTx treated with cyclosporine-based immunosuppression, era Ⅱ (2003-2006)-7 cases of SBTx treated with tacrolimus-based immunosuppression, and era Ⅲ (2007-present)-5 cases of SBTx treated with Alemtuzumab induction therapy and maintenance tacrolimus monotherapy. During era Ⅰ and era Ⅱ, Fluconazole Ⅳ was used as prophylaxis and treatment protocol. If the IFI was aggressive, Amphotericin B or Amphotericin B Liposome were also given with initial dose of 1-5 mg/d (or 0.02-0.10 mg·kg~(-1)·d~(-1). During era Ⅲ, 2-weeks Arnphotericin B Liposome was used as prophylaxis therapy after SBTx, and the dose of 6 mg· kg~(-1)·d~(-1) of Amphotericin B Liposome was given to treat IFI after SBTx. The administration manner of Amphotericin B Liposome was also improved during era Ⅲ, and the initial dose achieved 6 mg without gradually increasing process. Closely surveillance of vital sign, liver and renal function, and electrolyte was also carried out, and the doses of Amphotericin B Liposome were titrated according liver and renal function. Results Four of 15 SBTx recipients suffered from IFI with the occurrence rate of 26.7%, 1, 2 and 1 recipient(s) suffered from IFI during different 3 eras, respectively. Three recipients died of severe IFI after SBTx during era Ⅰ and era Ⅱ. One SBTx recipient with IFI during the era Ⅲ totally recovered after 44-days treatment of Amphotericin B Liposome with the totally dose of 9100 mg, and the renal dysfunction was observed and.ameliorated after ceasing of Amphotericin B Liposome. The mortality of these 4 IFI after SBTx was 75%. Conclusion IFI after SBTx is associated with high mortality rate. Amphotericin B Liposome can effectively control IFI after SBTx. With closely surveillance of recipient renal function, high dose of Amphotericin B Liposome can be safely used.
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Objective To study the effects of liver graft on the immune tolerance of intestinal allograft in auxiliary en-bloc liver-small bowel transplantation in pigs.Methods Seventy outbreed Landrace pigs were divided into 4 groups.Ten auxiliary liver-small bowel allotransplantations were performed in group A,B,C,respectively,and 5 segmental small bowel allotransplantatiom were performed in group D.Pigs were administered with routine and lower dose of cyclosporine and methylprednisolone in group B and C,respectively. No immunosuppressive agent was administered to pigs in group A and D.Results The initial time of acute rejection was obviously prolonged in group A than group D.and the acute rejection was milder in group A than group D(P＜0.05).There was no significant difference upon postoperative survival time,initial time of acute rejection and degree of acute rejection between group B and C(P＞0.05).Conclusions The immune tolerance of intestinal allograft Can be induced by liver graft in auxiliary en-bloc liver-small howel transplantation.
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Objective:To observe the applications of damage control surgery(DCS) theory in selective abdominal operations.Methods:Two patients suffered from abdominal huge tumour were included in this clinical observation.DCS method was used in the first case when uncontrollable haemorrhage happened in the operation.In the second case,the DCS method was planed before operation.Results:Both the two patients were healed.The second one had no dangerous states after operation.Conclusion:In selective abdominal operation,perioperative DCS method should be considered if some life-threatening risks may happen in the operative procedure.
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Objective: To observe the effect of nutritional support and metabolic intervention in a patient receiving combined liver and intestinal transplantation. Methods: Glycyl glutamine(Gly Gln)and arginine supplemented total parenteral nutrition(TPN) was administered since postoperative day(POD)1. Glutamine(Gln) and arginine supplemented enteral nutrition(EN) was applied since POD 4. Growth hormone(GH) was delivered intermittently since POD 4.With adaptation and tolerance, enteral feeding was progressively increased while parenteral nutrition reciprocally decreased. Results: Transplanted organs functioned well. Conclusions: Rehabilitation of the allograft function can profit from the application of nutritional support and metabolic intervention.
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Objectives: Early postoperative inflammatory ileus(EPII) is a special type of ileus. For its special pathophysiological and clinical characters, EPII is hard to be treated.The combination therapy including total parenteral nutrition(TPN), enteral nutrition(EN), somatostatin and cortin has been used to treat EPII. Methods: From May 2001 to December 2001, 10 EPII patients were treated and the changes of clinical symptoms, serum total protein, albumin, prealbumin and the curative effect were observed. Results: All patients were cured without operation. Two days after treatment, the gastric juice was reduced from (1 377.5?856.8)ml to (484.0?396.3)ml ( P = 0.037 ) but the serum total protein, albumin and prealbumin had no changes. The clinical symptoms subsided quickly. Average TPN time was 21 days and EN time was 9 days. The average time in hospital was 32 days. Conclusions:The combination therapy can obviously alleviate the clinical symptoms, maintain the nutritional status and promote the recovery of intestinal function in EPII patient.