Management of non traumatic surgical emergencies during the COVID-19 pandemia / Conduta nas urgências e emergências cirúrgicas não traumáticas durante a pandemia COVID-19

ABSTRACT In December 2019, in Wuhan, China, the first cases of what would be known as COVID-19, a disease caused by an RNA virus called SARS-CoV-2, were described. Its spread was rapid and wide, leading the World Health Organization to declare a pandemic in March 2020. The disease has distinct clinical presentations, from asymptomatic to critical cases, with high lethality. Parallel to this, patients with non-traumatic surgical emergencies, such as acute appendicitis and cholecystitis, continue to be treated at the emergency services. In this regard, there were several doubts on how to approach these cases, among them: how to quickly identify the patient with COVID-19, what is the impact of the abdominal surgical disease and its treatment on the evolution of patients with COVID-19, in addition to the discussion about the role of the non-operative treatment for abdominal disease under these circumstances. In this review, we discuss these problems based on the available evidence.

RESUMO Em dezembro de 2019, em Wuhan na China, foram descritos os primeiros casos do que seria conhecida como a COVID-19, doença causado por um RNA vírus denominado SARS-CoV-2. A disseminação foi rápida e ampla, levando a Organização Mundial de Saúde a decretar pandemia em março de 2020. A doença tem apresentação clínica variada, desde portadores assintomáticos até casos críticos, com alta letalidade. Paralelamente a isto, pacientes com urgências cirúrgicas não traumáticos, como apendicites agudas e colecistites agudas, continuam a ser atendidos nos serviços de emergências. Neste contexto, surgiram várias dúvidas sobre a conduta nestes casos, entre essas: como identificar rapidamente o paciente com COVID-19, qual o impacto da doença cirúrgica abdominal e o tratamento na evolução dos pacientes com COVID-19, além da discussão sobre o emprego de tratamento não operatório para a doença abdominal nestas circunstâncias. Nesta revisão, trazemos a discussão destes problemas sob a luz das evidências disponíveis.

Desnutrição e complicações clínicas em pacientes cirúrgicos com doença colorretal / Malnutrition and clinical outcomes in surgical patients with colorectal disease

ABSTRACT BACKGROUND: Malnutrition is a frequent condition among hospitalized patients and a factor of increased risk of postoperative complication. OBJECTIVE: This study aimed to evaluate the impact of malnutrition on phase angle (PA), body water distribution and clinical outcomes in surgical patients with colorectal disease. METHODS: This retrospective study was performed in a tertiary hospital with 40 patients admitted electively. In the preoperative evaluation, global subjective assessment and bioelectrical impedance analysis were performed to determine nutritional status, PA, extracellular water (ECW), intracellular water (ICW) and total body water (TBW). In postoperative evaluation, the length of hospital stay and severe complications, according to Clavien-Dindo classification, were determined. The optimal PA cutoff for malnutrition screening was determined by ROC curve analysis. RESULTS: Seventeen (42.5%) patients were diagnosed as malnourished and 23 (57.5%) as well-nourished according to global subjective assessment. Twelve (30.0%) patients developed severe complications. The malnourished group presented lower values of serum albumin (P=0.012), hematocrit (P=0.026) and PA (P=0.002); meanwhile, ECW/ICW (P=0.019) and ECW/TBW (P=0.047) were higher. Furthermore, 58.8% of malnourished patients developed severe postoperative complications compared to 8.7% of well-nourished. Malnutrition was independent predictor of severe postoperative complications (OR=15.00, IC: 2.63-85.68, P=0.002). The optimal PA cutoff obtained was 6.0º (AUC=0.82, P=0.001), yielding sensitivity, specificity, positive predictive value and negative predictive value of 76.5%, 87.0%, 81.3% and 83.4%, respectively. CONCLUSION: Malnutrition was an independent predictive factor for severe complications in patients underwent to elective major coloproctological surgery. Besides that, malnutrition was associated with lower PA values and greater ratio of ECW. The PA provided great accuracy in nutritional screening, implying a useful marker of malnutrition.

RESUMO CONTEXTO: A desnutrição é uma condição frequente entre pacientes hospitalizados e é um fator de risco para complicações pós-operatórias. OBJETIVO: Este estudo tem como objetivo avaliar o impacto da desnutrição sobre o ângulo de fase (AF), a distribuição de água corporal e complicações clínicas em pacientes cirúrgicos com doença colorretal. MÉTODOS: Trata-se de um estudo retrospectivo realizado em um hospital universitário terciário com 40 pacientes admitidos eletivamente. Na avaliação pré-operatória, foram realizadas a avaliação subjetiva global e análise de bioimpedância elétrica com a finalidade de determinarem o estado nutricional, AF, água extracelular (AEC), água intracelular (AIC) e água corporal total (ACT). Na avaliação pós-operatória, o tempo de internação hospitalar e a presença de complicações graves, segundo a classificação de Clavien-Dindo, foram determinados. O melhor ponto de corte do AF para o rastreamento de desnutrição foi obtido a partir da análise da curva ROC. RESULTADOS: Dezessete (42,5%) pacientes foram diagnosticados como desnutridos e 23 (57,5%), como bem nutridos de acordo com a avaliação subjetiva global. Doze (30,0%) pacientes desenvolveram complicações pós-operatórias graves. O grupo desnutrido apresentou menores valores de albumina sérica (P=0,012), hematócrito (P=0,026) e AF (P=0,002); enquanto que as relações de AEC/AIC (P=0,019) e AEC/ACT (P=0,047) estiveram elevadas. Além disso, 58,8% dos pacientes desnutridos desenvolveram complicações pós-operatórias graves em comparação a 8,7% dos pacientes bem nutridos. A desnutrição foi fator preditivo independente para o desenvolvimento de complicações pós-operatórias graves (OR=15,00, IC: 2,63-85,68; P=0,002). O melhor ponto de corte do AF obtido foi 6.0º (AUC=0,82; P=0,001) com sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de 76,5%, 87,0%, 81,3% e 83,4%, respectivamente. CONCLUSÃO: A desnutrição foi fator preditivo para o desenvolvimento de complicações graves em pacientes submetidos à cirurgia eletiva coloproctológica de grande porte. Além disso, a desnutrição foi associada a menores valores de AF e maior proporção de AEC. O AF forneceu boa acurácia no rastreamento da desnutrição, sugerindo seu uso como potencial marcador de desnutrição.

Analysis of double balloon enteroscopy: indications, findings, therapeutic and complications / Análise da enteroscopia por duplo balão: indicações, achados, terapêutica e complicações

ABSTRACT Background: The double balloon enteroscopy is an important method for the endoscopic approach of the small bowel that provides diagnosis and therapy of this segment's disorders, with low complication rate. Aim: Analysis of patients undergoing double balloon enteroscopy. The specific objectives were to establish the indications for this method, evaluate the findings by the double balloon enteroscopy, analyze the therapeutic options and the complications of the procedure. Methods: It is a retrospective analysis of 65 patients who underwent double balloon enteroscopy. Results: Sixty-five procedures were performed in 50 patients, 63.1% were women and 36.9% were men. The mean age was 50.94 years. The main indication it was gastrointestinal bleeding, followed by abdominal pain and Crohn's disease. Most procedures were considered normal. Polyps were the most prevalent finding, followed by angioectasias and duodenitis. In 49.2% of the cases, one or more therapeutic procedures were performed, (biopsy was the most prevalent). There was only one case of acute pancreatitis, which was treated clinically. Conclusion: The enteroscopy is good and safe method for the evaluation of the small bowel, and its main indications are gastrointestinal bleeding and abdominal pain. It has low complications rates and reduces the necessity of surgery.

RESUMO Racional: A enteroscopia por duplo balão é importante método endoscópico para abordagem do intestino delgado, permitindo o diagnóstico e a terapêutica de afecções com baixa taxa de complicações. Objetivo: Análise de pacientes submetidos à enteroscopia por duplo balão, estabelecendo as indicações para realização do exame e seus achados, analisando a terapêutica realizada e observando as complicações decorrentes do procedimento. Métodos: Estudo retrospectivo de análise de 65 prontuários de pacientes submetidos à enteroscopia por duplo balão. Os dados foram armazenados em planilhas e foi realizada a análise estatística. Resultados: Foram 65 enteroscopias em 50 pacientes, sendo 63,1% mulheres e 36,9% homens, com média de idade de 50,94 anos. A principal indicação foi sangramento intestinal, seguida por dor abdominal e doença de Crohn. A maioria dos procedimentos foi considerada normal, sendo que o achado mais prevalente foram os pólipos, seguido por angioectasias e duodenites. Em 49,2% dos exames foi realizado algum procedimento terapêutico, sendo a biópsia o mais prevalente. Houve apenas um caso de complicação de pancreatite aguda. Conclusão: A enteroscopia por duplo balão é bom e seguro método para a avaliação do intestino delgado, possuindo como principais indicações o sangramento intestinal e a dor abdominal. Possui baixas taxas de complicações e, por meio de suas opções terapêuticas, diminui a necessidade de procedimentos cirúrgicos.

Fast-track surgery in India.

Fast-track surgery or ‘enhanced recovery after surgery’ or ‘multimodal rehabilitation after surgery’ is a form of protocolbased perioperative care programme. It is an amalgamation of evidence-based practices that have been proven to improve patient outcome independently and exert a synergistic effect when applied together. The philosophy is to treat the patient’s pathology with minimal disturbance to the physiology. Several surgical subspecialties have now adopted such protocols with good results. The role of fast-track surgery in colorectal procedures has been well demonstrated. Its application to other major abdominal surgical procedures is not as well defined but there are encouraging results in the few studies conducted. There has been resistance to several aspects of this programme among gastrointestinal and general surgeons. There is little data from India in the available literature on the application of fast-tracking in gastrointestinal surgery. In a country such as India the existing healthcare structure stands to gain the most by widespread adoption of fast-track methods. Early discharge, early ambulation, earlier return to work and increased hospital efficiency are some of the benefits. The cost gains derived from this programme stand to benefit the patient, doctor and government as well. The practice and implementation of fast-track surgery involves a multidisciplinary team approach. It requires policy formation at an institutional level and interdepartmental coordination. More research is required in areas like implementation of such protocols across India to derive the maximum benefit from them.

Aspectos relevantes en la realización de la endoscopia digestiva: propuestas basadas en la evidencia. Curso ACHED 2013 / Relevant aspects of digestive endoscopy. Evidence-based suggestions. Chilean Association of Digestive Endoscopy (ACHED), Course 2013

Digestive endoscopy is a complex tool for diagnosis and treatment, with continuous development both in technical aspects and in their application for the different pathologies where this technique is required. Therefore, a continuous education program is necessary for the practitioner using this technique. With the purpose of reaching an agreement between different aspects of the performance of these procedures and also generating proposals for its application that are useful for the physicians of this area of expertise, during 2013 the Chilean Association of Digestive Endoscopy (ACHED) developed a workshop called ‘Relevant aspects of digestive endoscopy. Evidence-based suggestions’. This workshop was attended by gastroenterologists and trainee practitioners, who worked in groups during a period of two months where they reviewed available evidence to answer several questions relating to milestones and lesions that need to be described in upper gastrointestinal endoscopy, the preparation of the GI endoscopy report, technical aspects and quality measures in colonoscopy. This review resulted in proposals that were analyzed and agreed on in the form of recommendations presented for further analysis and discussion amongst endoscopic teams in our country.

La endoscopia digestiva es una herramienta de diagnóstico y tratamiento médico compleja, en continuo desarrollo tanto en lo técnico como en los conceptos de manejo de las patologías en las que se utiliza.Por lo tanto, es deseable una estrategia de formación continua del profesional que la realiza. Con el objetivode consensuar diferentes aspectos en la realización de estos procedimientos y generar propuestas de manejoque sean de utilidad para todos los médicos involucrados en esta especialidad, la Asociación Chilenade Endoscopia Digestiva (ACHED) realizó durante el año 2013 un curso taller denominado “Aspectosrelevantes en la realización de la endoscopia digestiva. Propuestas basadas en la evidencia”. Este cursoconvocó a gastroenterólogos y médicos en formación de la especialidad que conformaron grupos de trabajoque durante 2 meses revisaron la evidencia disponible para responder diversas preguntas en relación a los hitos y lesiones a describir en endoscopia digestiva alta (EDA), la realización del informe en EDA, aspectos técnicos y medidores de calidad en colonoscopia. La revisión les permitió generar propuestas que fuerondiscutidas y consensuadas en recomendaciones que se proponen para su discusión por los equipos endoscópicos de nuestro país.

Resultados clínicos y funcionales de la cecoproctoplastia con rotación anti horaria - Experiencia preliminar / Clinical and functional results of the ceco proctoplasty with anti clockwise rotation - Preliminary experience

Introducción: la colectomía subtotal con anastomosis cecorrectal o cecoproctoplastia, es una alternativa a la colectomía total con anastomosis ileorrectal; permite conservar el íleon distal, válvula ileocecal y el ciego preservando las importantes funciones de absorción. El objetivo del trabajo es observar los resultados clínicos y funcionales post operatorios de la cecoproctoplastia. Materiales y Métodos: los pacientes seleccionados con promedio de 57 años de edad, fueron 3 (tres) casos de diverticulosis colónica complicada, 2 (dos) casos con hemorragia y 1 (uno) con diverticulitis, 1 (uno) caso de angiodisplasias múltiples y 1 (uno) caso de cáncer de colon sigmoides, adenocarcinoma bien diferenciado T2 N0 M0, todos fueron sometidos a colonoscopia y en cuatro de ellos se efectuó enema opaco y todos presentaban válvula ileocecal continente. La técnica, sigue la propuesta de Zinzidohoue. Resultados: no se registraron mortalidad ni complicaciones mayores. Los resultados funcionales en relación a la cantidad y característica de las deposiciones diarias al año del postoperatorio, todos los pacientes presentaron 2 a 3 deposiciones diarias. Discusión: en 1998, Zinzidohoue propuso una modificación a la técnica de Deloyers en la colectomía subtotal con conservación de la unión ileocecal, que preserva la continuidad anastomosando el ciego al muñón rectal. Esta técnica, representa actualmente una alternativa a la colectomía total con anastomosis ileorrectal considerado a menudo como insatisfactorio debido a la alta frecuencia de diarrea y alto índice obstrucción del intestino delgado. Conclusión: nuestra experiencia preliminar, nos permite afirmar que la cecoproctoplastia es una técnica aconsejable en seleccionados casos, representa una alternativa a la ileoproctoanastomosis por sus resultados clínicos y funcionales satisfactorio.

Background: subtotal colectomy with cecorrectal anastomosis or cecoproctoplasty is an alternative to total colectomy with ileorectal anastomosis. It allows keeping the distal ileon, the ileocaecal valve and the cecum, preserving important absorption functions. This work is aimed to evaluate the postoperative clinical and functional outcomes from cecoproctoplasty technique. Materials and methods: five patients with a mean age of 57 years old were selected. Three of them were suffering from complicated colonic diverticulitis, 2 with hemorrhage and 1 with diverticulitis; 1 case of multiple angiodysplasia and 1 with sigmoid colon cancer, well-differentiated adenocarcinoma T2N0M0. All of them undergone colonoscopy, in 4 of them were performed x ray with barium enema. All patients presented good continence of the ileocaecal valve. The technique is based on the proposal of Zinzidohoue. Results: there was no mortality and no postoperative complication. Functional outcomes regarding the number and characteristics of mean daily stool frequency over a year was 2-3. Discussion: by 1998, Zinzidohoue proposed a Deloyers’ technique modification in subtotal colectomy with ileocaecal junction conservation, which keeps the continuity, joining the cecum to the rectal stump. This technique represents an alternative to total colectomy with ileorectal anastomosis. It is often considered as unsatisfactory because of the high rate of diarrhea and small intestine obstruction. Conclusion: our preliminary experience allows us to state that cecoproctoplasty is a recommended technique in selected cases. It represents an alternative to ileorectal anastomosis because of its satisfactory clinical and functional results.

Endoprótesis autoexpandibles en tubo digestivo: estado actual / Stents in the digestive tract: state of the art

Las endoprótesis son dispositivos usados actualmente para el tratamiento paliativo y definitivo en los casos de obstrucciones malignas del tubo digestivo y temporal en los casos benignos como estenosis, fístulas o perforaciones. Los avances obtenidos en el diseño y los sistemas de liberación de estas prótesis han tenido un progreso extraordinario, que por consiguiente, hoy son consideradas como un tratamiento mínimamente invasivo. La evolución de estas prótesis permitirá a los pacientes no solo un tratamiento paliativo sino también una posibilidad curativa con la liberación de drogas antimitóticas (Idionine 125). Además, con el uso de materiales biodegradables en las mismas, permitirá la disminución entre el número de procedimientos y las complicaciones.

Stents are devices currently used for palliative and definitive treatment in cases of malignant obstructions of the digestive tract and nowadays can be used in benign cases like stenosis, fistulas or perforations. The progress made in the design and delivery systems of these prostheses have been of extraordinary benefit, which consequently are now considered as a minimally invasive treatment. The evolution of these prostheses allows patients not only a palliative treatment but also a possibility of curative option, due to antimitotic drug release (Idionine 125). In addition, the use of biodegradable materials in them, enable the reduction of the rate of complication, related with the number of procedures.

Nuevas técnicas en cirugía endoscópica gastrointestinal / New techniques in gastrointestinal endoscopic surgery

Desde la década de los setenta ha ido evolucionando la cirugía endoscópica gastrointestinal logrando grandes cambios en los paradigmas del manejo de algunas patologías como la hemorragia digestiva, la resección de pólipos y el manejo de la vía biliar tanto diagnóstico como terapéutico. El desafío actual es lograr el desarrollo de técnicas endoscópicas que permitan el tratamiento de patologías como el cáncer incipiente, la obesidad mórbida, el reflujo gastroesofágico y la acalasia. Este artículo informa sobre las nuevas técnicas y las expectativas hacia el futuro en el manejo endoscópico de estas enfermedades.

Gastrointestinal endoscopic surgery has been making great progress since the seventies in the management paradigms of conditions such as gastrointestinal bleeding, polyp resection and diagnostic and therapeutic management of the biliary tract. The current challenge is the development of techniques that allow endoscopic treatment of emerging diseases such as cancer, morbid obesity, gastro-esophageal reflux and achalasia. This article reports on new techniques and expectations for the future in the endoscopic management of these diseases.

Consideraciones sobre un caso singular de mutilación digestiva / Considerations an a singular case of digestive mutilation

El contenido de este trabajo se ajusta a la presentación de un caso notable que expone dos particularidades primordiales: 1) paciente sometida sucesivamente a: colectomía total, colecistectomía, gastrectomía total y ulteriormente a resección de los dos tercios superiores del recto; y 2) que haya sido factible practicar una evaluación clínica y paraclínica a más de tres décadas de la primera intervención quirúrgica, posibilitando de este modo estimar y debatir distintos ángulos de enfoque del caso en cuestión.

The remarcable case presented on this paper has two special characteristics: 1) the patient received, sequentially, a total colectomy, a cholecystectomy, a total gastrectomy and a resection of the two upper thirds of the rectum; and 2) the fact that it was feasible to make a clinical and paraclinical assesment more than three decades after the first surgery, making it possible to consider and to debate the different approaches towards this particular case.

Critical analysis of the use of statistical tests in Brazilian publications related to digestive tract surgery / Análise crítica do uso de testes estatísticos em publicações Brasileiras relacionadas à cirurgia do aparelho digestivo

OBJECTIVE: To evaluate the evolution of scientific papers published on digestive tract surgery in Brazilian journals in 20 years and examine whether the level of evidence in the studies has improved, as well as the incorporation of statistical procedures and their proper application. METHODS: We selected all original articles related to digestive tract surgery published in the years of 1987 and 2007 in 4 leading Brazilian surgical journals. Studies were divided according to the level of evidence (I: prospective, controlled and randomized, II: prospective without control or randomization and III: retrospective) and compared them to assess whether there was an improvement in the level of evidence between these two years surveyed. We also assessed whether there was increased use of analytical statistics and correct application of statistical procedures. RESULTS: Comparing the articles published in 1987 with those of 2007, we observed no improvement with respect to the level of evidence, with more than half of the articles published being case series and retrospective studies (56.14 percent). There has been a significant increase in the use of analytical statistics (70.4 percent in 2007 vs. 40 percent in 1987) in the 20 years, however 16.7 percent of the studies published in 2007 did not correctly apply or adequately describe the statistical analyses used. CONCLUSION: In this study, we observed no improvement in the level of evidence presented in publications on digestive tract surgery in the last 20 years. There was an increased use of statistical analysis, but there is a need to correctly apply statistical procedures.

OBJETIVO: Avaliar a evolução dos trabalhos publicados sobre cirurgia do aparelho digestivo em revistas brasileiras nos últimos 20 anos, observando se houve melhora no nível de evidência destes trabalhos além da incorporação de procedimentos estatísticos e a sua correta aplicação. MÉTODOS: Selecionamos todos os artigos originais relacionados à cirurgia do aparelho digestivo publicados nos anos de 1987 e 2007 em quatro revistas cirúrgicas nacionais de renome. Os estudos foram divididos de acordo com o nível de evidência (I: prospectivo, randomizado e controlado, II: prospectivo sem controle ou randomização e III: retrospectivo) e comparados para avaliar se houve melhora do nível de evidência entre os dois anos avaliados. Também observamos se ocorreu aumento no uso de estatística analítica e a correta aplicação dos procedimentos estatísticos. RESULTADOS: Comparando os artigos publicados em 1987 com os de 2007, não observamos melhora no nível de evidência, com mais de metade dos artigos publicados tratando de séries de casos e estudos retrospectivos (56,14 por cento). Houve um aumento significante na utilização de estatística analítica (70,4 por cento em 2007 vs. 40 por cento em 1987) nos últimos 20 anos, mas 16,7 por cento dos estudos publicados em 2007 não aplicavam corretamente ou descreviam adequadamente a análise estatística utilizada. CONCLUSÃO: Neste estudo observamos que não houve melhora no nível de evidência das publicações brasileiras relacionadas à cirurgia do aparelho digestivo nos últimos 20 anos. Houve aumento do uso de estatística analítica, porém existe a necessidade de se observar a correta aplicação dos procedimentos estatísticos.

Soporte nutricional en pacientes sometidos a cirugía gastrointestinal / Nutritional support to patients undergoing gastrointestinal surgery

La depleción nutricional ha demostrado ser el principal determinante en el desarrollo de complicaciones postoperatorias. Los pacientes sometidos a cirugía gastrointestinal están en riesgo de sufrir depleción nutricional debido a ingesta inadecuada, estrés quirúrgico e incremento del gasto metabólico. La presencia de íleo postoperatorio y la integridad de la nueva anastomosis han llevado a mantener un ayuno con administración de líquidos parenterales hasta que el paciente comience con ruidos intestinales o elimine gases. Sin embargo, se ha visto que la nutrición postoperatoria enteral precoz es efectiva y bien tolerada. La alimentación enteral se asocia también con beneficios clínicos tales como la reducción en la incidencia de complicaciones infecciosas postoperatorias y una mejoría en la cicatrización de los tejidos. Los estudios indican que la reducción significativa de morbimortalidad asociada a nutrición parenteral total se limita a aquellos pacientes severamente desnutridos portadores de neoplasias gastrointestinales. Un metaanálisis ha mostrado que la nutrición enteral se asocia con menores complicaciones sépticas, reducción de costos y menor estadía hospitalaria si se la compara con la nutrición parenteral, por lo que debería ser de elección cuando sea posible. Parece no haber claras ventajas en mantener a los pacientes con "nada por boca" después de una reseccción gastrointestinal electiva. La nutrición enteral siempre es beneficiosa. La evidencia a favor del soporte nutricional preoperatorio es limitada, pero sugiere que si los pacientes desnutridos son adecuadamente alimentados por 7-10 días previos a la cirugía, los resultados postquirúrgicos pueden mejorar. Se están explorando los beneficios potenciales de la glutamina sobre el intestino y el sistema inmune en pacientes sometidos a cirugía gastrointestinal. Hasta la fecha se ha demostrado que la nutrición parenteral enriquecida con glutamina reduce la estancia hospitalaria y los costos en paciente...

Current Application of Minimally Invasive Surgery for Gastrointestinal Diseases / 대한소화기학회지

The advent of minimally invasive surgery (MIS) brought a major deviation in trend from conventional surgery. Since the introduction of first laparoscopic cholecystectomy in 1985, many operations for gastrointestinal diseases adopted MIS technique in a relatively short period of time. These MIS operations yielded better outcomes when compared to their open counterparts: less pain, shorter hospital stay, faster recovery, and better cosmetics. More complex surgical procedures for benign and malignant diseases of gastrointestinal tract are currently being performed by MIS technique with the improvement in equipment, instrumentation, and surgical skills. At the forefront of MIS, lies robotics. This paper briefly reviews the current status of MIS in the field of gastrointestinal diseases.

Robotic Surgery in Gastrointestinal Surgery / 대한소화기학회지

Robotic surgery is an emerging technology. After adoption of robotic surgery for cholecystectomy in 1997, various general surgical procedures have been performed using surgical robot. In general surgery, robotic surgery is applied to wide range of procedures, however, it is still in its early years. Cholecystectomy, Nissen fundoplication, Heller myotomy, and Roux-en-Y gastric bypass are the most frequently performed robotic operations. Most reports proved that application of robotic technology for general surgery is technically feasible and safe with the help of improved dexterity, better visualization, and high level of precision. However, still the absence of tactile sense and extremely high costs are the problems to be solved. Although robotic surgery has demonstrated some clear benefits compared to conventional surgeries including laparoscopy, it remains to be seen whether these benefits will outweigh the associated disadvantages or problems of robot surgery. Therefore, more prospective randomized study comparing the shot-term and long-term surgical outcomes between robotic and conventional laparoscopic surgery is needed to further define the impact of robotic surgical technology in general surgery.

Schistosomiasis mansoni and severe gastrointestinal cytomegalovirus disease in a patient with acquired immunodeficiency syndrome

The behavior of the Schistosoma mansoni infection in patients with AIDS has not been explored. The case of a young woman with schistosomiasis mansoni, AIDS, and cytomegalovirus disease is reported. The authors suggest that the helminth was not a bystander in this case, or rather, by interfering with the host's immune response, it set the stage for the development and/or aggravation of the viral infection.

O comportamento da infecção pelo Schistosoma mansoni não foi explorado em pacientes com AIDS. Relatamos aqui o caso de uma paciente com esquistossomose mansoni, AIDS, e doença pelo citomegalovírus. Os autores sugerem que o helminto não foi apenas um espectador neste caso, mas, que, ao interferir na resposta imune do hospedeiro, promoveu o surgimento e/ou agravamento da infecção causada pelo citomegalovírus.

Mortality at Ibn sina surgical gastroenterology unit as predicted by possum with brief literature review

Failure to identify the high ris k factors for surgery and/or anesthesia is a serious medico-legal pitfall particularly if unexpected consequences ensue. Compare the mortality rate at Ibn Sina Surgical gastro-intestinal unit using POSSUM predicted mortality with the observed mortality. A prospective collection of data for patients admitted in 6-month period. Demographic data, symptoms, co-morbid illnesses, physical examination, results of investigations, operative findings were recorded as well as the follow up for one month. The data was fed to a POSSUM computer program to determine the predicted mortality. The univariate and multivariate analysis was done with SPSS. 252 patients were studied. They were 132 [52.4%] males. Mean [ +/- SD] age 49[ +/- 12.29] range 10-90 years. 216 [85.7%] patients underwent suigrey. The overall observed mortality was 32 [12.7%] patients. 10 [27.8%] patients died before surgery. The highest mortality was 9 [27.3%] in cases of carcinoma head of pancreas. Carcinoma of the stomach has observed mortality of 6 [42.9%] patients while its predicted mortality range from 1.7% to 35.7% with mean of 17.9%. Multivariate analysis showed that factors which have significant association with the observed mortality are the physiological score P 0.0001, age P 0.0001, predicted mortality P 0.0001 and inoperability P 0.0020. POSSUM has under-predicted mortality in gastric, oesophageal and cholangiocarcinoma. The out come of management of other types of cancer as oesophageal and colorectal cancer as well as the benign diseases of the gastrointestinal tract is consistent with the predicted values of the POSSUM. Therefore POSSUM is a good risk adjusted criteria for predicting mortality in GIT surgical diseases at Ibn Sina Hospital

Stem Cell Research in Gastroenterology / 대한소화기학회지

Stem cells are undifferentiated cells capable of undergoing self-renewal and differentiation into a variety of cell types. They are derived from adult tissues (adult stem cells) as well as embryonal blastocysts (embryonic stem cells). Embryonic stem cells have pleuripotent capacity able to form tissues of all three germ layers but many ethical controversies concerning resource allocation or methods of harvesting are arising. Recently, many studies have demonstrated the multipotency of adult stem cells, but the mechanism of the plasticity remains to be determined yet. Several studies have suggested the possibilities of application of stem cells or tissue specific cells to regenerate gastroenterologic diseases such as liver cirrhosis, hepatitis, or inherited metabolic disorders. However, most of those trials are still limited to animal models, although anecdotal claims of successful therapy in humans have been reported. Even though the expectations and the promise of cell therapy are high, clinical efficacy has not been definitely demonstrated at this time. Thus, the application of cell therapy cannot be recommended to the patients outside the clinical trial setting.

Role of octreotide in postoperative enterocutaneous fistula

Postoperative enterocutaneous fistulae, a serious complication of gastrointestinal surgery are associated with significant morbidity and mortality. Its management is based on nutritional support, control of sepsis, skin and wound care while waiting for fistula to close. Octreotide, a long acting somatostatin analogue, reduces gastrointestinal secretions and motility, hence reducing fistula output. Thirty one patients with postoperative enterocutaneous fistulae were administered octreotide subcutaneously and its effect on fistula output, till closing time were noted. There was a significant reduction in the fistula output, in 23[74%] patients fistula closed spontaneously in second week. Skin and wound were also easily managed. Although fistulahealing time was apparently reduced but, it was not possible to prove reduction in healing time convincingly, as to this end, controlled double blind trials are required. It is however, concluded that octreotide significantly reduces the morbidity by reducing - fistula output and assists in better skin and wound care

Comparison of ondansetron and placebo for preventing postoperative nausea and emesis in gastrointestinal tract surgery: a multicenter randomized controlled trial.

BACKGROUND: Nausea and emesis are undesirable events that may cause discomfort and suffering in the postoperative period. This study was carried out to evaluate the efficacy and safety of ondansetron for preventing postoperative nausea and vomiting in patients undergoing gastrointestinal tract surgery. METHODS: Using a randomized double-blind study design, 408 surgical patients (163 male and 245 female) receiving general endotracheal anesthesia were studied at five medical centers in Bangkok. Ondansetron (4 mg) or placebo was administered prior to induction of anesthesia. Episodes of nausea and vomiting, adverse events and laboratory tests (complete blood count and liver function test) were evaluated during 24 hours after study drug administration. RESULTS: The incidence of postoperative nausea and vomiting in the placebo group (42.7 and 35.2%) were significantly higher than the ondansetron group (23.9 and 15.4%). However, no significant differences occurred in the incidence of adverse events or changes in laboratory tests in the ondansetron group compared to the placebo group. CONCLUSIONS: Ondansetron 4 mg given intravenously before surgery is safe and effective for preventing postoperative nausea and emesis following gastrointestinal tract surgery.