Clinical characteristics of non-perianal fistulating Crohn's disease in China: a single-center experience of 184 cases / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>There is little information of non-perianal fistulating Crohn's disease in the consensus published by the European Crohn's and Colitis Organization in 2006 and 2010. This study was designed to demonstrate the clinical characteristics of non-perianal fistulating Crohn's disease among homogenous Chinese population.</p><p><b>METHODS</b>One-hundred-and-eighty-four patients were retrospectively collected. All of these patients were diagnosed of Crohn's disease between February 2001 and April 2011.</p><p><b>RESULTS</b>The male-to-female ratio was 2.7:1. The most common symptoms at onset were abdominal pain (88.0%), diarrhea (34.7%), and fever (28.3%). The most common disease location and behavior at diagnosis were small bowel (56.0%) and penetrating (51.6%). Among 324 non-perianal fistulae, the most common types were ileocolonic anastomotic (30.9%), terminal ileocutaneous (19.7%), and enteroenteric anastomotic (11.4%). One-hundred-and-thirty- eight (75.0%) patients received antibiotics, and β-lactam (85.5%) and metronidazole (67.4%) are most frequently used. One-hundred-and-seventy-eight (96.7%) patients suffered 514 surgical operations, and the cumulative surgical rates after 1, 3, and 5 years were 38.0%, 52.2%, and 58.7% respectively. Nine patients died during the follow-up period, and the cumulative survival rates after 1, 3, and 5 years were 97.8%, 96.7%, and 96.2% respectively.</p><p><b>CONCLUSIONS</b>This study displayed the clinical characteristics of non-perianal fistulating Crohn's disease in our center. Large population-based studies are required for further investigation in China.</p>

Influence of Lipoplus fat emulsion on postoperative nutritional status and early inflammatory response in patients with gastrointestinal malignancies / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effect of Lipoplus on postoperative nutritional status and inflammatory response in patients with gastrointestinal malignancies.</p><p><b>METHODS</b>Sixty-four patients with gastrointestinal malignancies were randomized using random digit table to receive isonitrogenous, isocaloric total parenteral nutrition for 5 days including either Lipoplus or Lipofundin with 32 patients in each group. Blood samples were obtained before the surgery, postoperative days 1, 2, 3, and 6 to evaluate the nutritional status(prealbumin, retinol binding protein, and nitrogen balance) and inflammatory response [C-reaction protein(CRP), and leukotriene(LTB) 5, LTB4]. The incidence of postoperative systemic inflammatory response syndrome(SIRS), infection, postoperative complications, mortality, APACHEII score, length of hospital stay and other clinical indicators were recorded.</p><p><b>RESULTS</b>On postoperative day 1, prealbumin and retinol binding protein were significantly lower as compared to preoperative levels. These parameters increased significantly(P<0.05) on postoperative day 6 and the nitrogen balance was positive. On postoperative day 6, CRP was significantly lower in both groups as compared to postoperative day 3 (P<0.05), and the decrease was more prominent in Lipoplus than Lipofundin(P<0.05). There was a significant increase in LTB5/LTB4 as compared to postoperative day 1(P<0.05) in the Lipoplus group, however the increase was not statistically significant in the Lipofundin group(P>0.05). The incidence of postoperative infection was significantly lower in the Lipoplus group(3.1% vs. 6.3%, P<0.05), as was that of SIRS(9.4% vs. 15.6%, P<0.05). The APACHEII score was higher in the Lipoplus group but the difference was not statistically significant(3.6±2.0 vs. 3.3±2.1, P>0.05). The length of hospital stay was significantly shorter in Lipoplus group[(6.4±1.1) d vs. (8.2±1.3) d, P<0.05].</p><p><b>CONCLUSION</b>Lipoplus can improve the postoperative nutritional status and minimize the inflammatory response in patients with gastrointestinal malignancies.</p>

Interpretation of the updated guidelines for prevention of surgical site infection / 中华胃肠外科杂志

The Guideline for prevention of surgical site infection had been published by the Centers for Disease Control for over 10 years. The Updated Recommendations for Control of Surgical Site Infections was published based on large amount of research results; last year, which focused on reduction in contamination, reduction in consequences of contamination and improvement of host defense. This article aims to review these guidelines so that improve clinical practice and decrease the complication of surgical site infection.

Effect of neoadjuvant chemotherapy on the postoperative pulmonary infection of patients with advanced gastric cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the effect of neoadjuvant chemotherapy on the postoperative pulmonary infection of patient with gastric cancer.</p><p><b>METHODS</b>Between January 2009 and January 2011, 139 patients with curable stage T2N2 or T3N2 gastric cancer were randomly assigned to group 1(69 cases, neoadjuvant chemotherapy with combined preoperative intraarterial infusion and intravenous chemotherapy before gastrectomy and D2 lymphadenectomy) and group 2(70 cases,gastrectomy and D2 lymphadenectomy alone). The morbidity of postoperative pneumonia in the two groups were recorded respectively.</p><p><b>RESULTS</b>The two groups were similar with respect to various clinical or pathological characteristics. All the patients underwent gastrectomy and D2 lymphadenectomy successfully. Eight patients in group 1 suffered from the postoperative pneumonia, accounting for 11.6%. Nine patients in group 2 suffered from the postoperative pneumonia, accounting for 12.9%. There was no significant difference between the two groups about the incidence of postoperative pneumonia.</p><p><b>CONCLUSION</b>Surgery following neoadjuvant chemotherapy with combined preoperative intraarterial infusion and intravenous chemotherapy is safe with similar morbidity of postoperative pneumonia to immediate surgery in patients with locally-advanced resectable gastric carcinoma.</p>

Experimental study of liver injury in rats of abdominal infection with abdominal compartment syndrome / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the liver injury in rats of abdominal infection complicated with abdominal compartment syndrome(ACS).</p><p><b>METHODS</b>SD rats were divided into four groups, including the sham group, the abdominal infection group, the ACS group, and the abdominal infection plus ACS group (combination group). Rats were sacrificed at 1 h, 6 h, 12 h, 24 h after operation with 6 rats at each time point. Blood specimens were collected for liver function testing. Liver tissues were assessed by pathologically examination with hepatic injury severity scoring(HISS). The expressions of Toll-like receptor 4 (TLR4),TNF-α and IL-6 were examined by reverse transcription- polymerase chain reaction.</p><p><b>RESULTS</b>At 24 h after operation, as compared to the sham group(18.2±1.3) U/L and (105.6±25.5) U/L, ALT and AST increased obviously in the abdominal infection group(68.2±17.5) U/L and (184.6±36.1) U/L, the ACS group (305.2±128.2) U/L and (638.0±104.8) U/L and the combination group (409.2±67.1) U/L and (743.2±250.2) U/L, while the combination group had a higher level as compared to the infection group and the ACS group(all P<0.05). HISS scores were significantly higher in the abdominal infection group(5.0), the ACS group(5.5) and the combination group(7.0) as compared to the sham group(1.5), but no significant differences were found among the three groups at 24 h after operation. Expressions of TLR4, TNF-α and IL-6 were significantly higher in combination group than those in the other three groups.</p><p><b>CONCLUSIONS</b>Liver function can be affected by abdominal infection and ACS. Abdominal infection plus ACS results in more severe liver injury.</p>

Open abdomen management treatment of liver injury in rats with abdominal compartment syndrome and sepsis / 中华外科杂志

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

Neoadjuvant chemotherapy of FLEEOX regimen for unresectable gastric cancer resulting from advanced abdominal lymph nodes metastases / 中华外科杂志

<p><b>OBJECTIVE</b>To observe the therapeutic response of advanced gastric cancer with severe lymph nodes metastasis to FLEEOX regimen neoadjuvant chemotherapy that combined arterial and venous administration.</p><p><b>METHODS</b>Neoadjuvant chemotherapy was administered to 32 cases of gastric cancer with advanced abdominal lymph nodes metastases from January 2007 to October 2008. Of the 32 patients, 28 had severe local lymph nodes metastasis, such as No.3, 7, 9, 12 lymph nodes metastasis, one patient had No.16 lymph nodes metastasis, and the other 3 patients had both regional and No.16 lymph nodes metastasis under CT scan. Neoadjuvant chemotherapy was administered as follows: 5-Fu 370 mg/m(2), intravenous drip, day 1 - 5; Leukovorin 120 mg, intravenous drip, day 1 - 5; oxaliplatin 150 mg/m(2), epirubicin 30 mg/m(2) and epotoside 70 mg/m(2), intravascular infusion through arteria gastrica sinistra, day 6 and 20. The protocol was repeated every five weeks for two or three courses. After 2 or 3 cycles of chemotherapy, abdominal CT was taken to evaluate the radiological therapeutic response and calculate the reductive rate of the tumor.</p><p><b>RESULTS</b>The general conditions and symptoms was improved significantly in all the patients. Four cases got complete response (CR), 24 got partial response (PR) and 4 got no change under CT scan. For the 32 case, the radiological response rate (CR + PR) was 87.5%(28/32). Thirty patients underwent subtotal or total gastrectomy, even combined organ resection, with D2 or D2 + alpha lymphadenectomy.</p><p><b>CONCLUSIONS</b>The FLEEOX regimen which combines arterial and venous administration carries a satisfactory therapeutic effect in advanced gastric cancer with severe lymph nodes metastasis. The combined routes of drug administration may improve the effects of neoadjuvant chemotherapy in stomach cancer.</p>

Efficacy of polyglycosides of Tripterygium wilfordii in preventing postoperative recurrence of Crohn disease / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To observe the efficacy of polyglycoside of Tripterygium wilfordii(GTW) in preventing postoperative recurrence of Crohn disease(CD).</p><p><b>METHODS</b>Thirty-nine post-operative CD patients in whom all of the diseased gut had been removed from January 2005 to December 2006 were enrolled in a randomized, placebo-controlled trial. The patients took GTW(21 cases) or SASP(18 cases) in two weeks after operation. Crohn disease activity index(CDAI), ESR and CRP were collected at week 0, 13, 26, 52 or at the onset of symptoms. Ileocolonoscopy was performed at the end of the trial or at the onset of symptoms.</p><p><b>RESULTS</b>One patient in GTW group and 2 patients in SASP group were lost and 2 patients in GTW were excluded from the trial for non-compliance. Clinical recurrence was ascertained in one patient (5.6%) received GTW and in four (25.0%) received SASP. Four of eighteen patients in GTW(22.2%) had endoscopic recurrence compared with nine of sixteen(56.2%) in SASP. There were significant differences between the two groups(P<0.05).</p><p><b>CONCLUSION</b>Tripterygium wilfordii showed good efficacy in preventing recurrence of postoperative CD which can maintain remission and prevent recurrence.</p>

Arteriovenous neoadjuvant FLEOX chemotherapy with nutritional support improves the resectable rate for advanced gastric cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To summarize the resectable rate of advanced gastric cancer characterized by abdominal lymph node metastases with the arteriovenous neoadjuvant FLEOX chemotherapy plus appropriate nutritional support.</p><p><b>METHODS</b>Arteriovenous neoadjuvant FLEOX chemotherapy was administered to 50 patients of gastric cancer with advanced abdominal lymph node metastases. Of the 50 patients, 42 had never received any previous therapy and preoperative CT scanning revealed unresectable tumors because of advanced lymph node (station No.3, 7, 9, 12) or distant lymph node (No.14,16) metastases. The other 8 were characterized with relapse of severe lymph node metastases or with unresectable lymph node metastases demonstrated by exploratory laparotomy. Arteriovenous neoadjuvant FLEOX chemotherapy was conducted as follows: from day 1 to day 5, 5-FU 370 mg/m(2) and leukovorin 30 mg/kg intravenously, at day 6 and day 20, CDDP 70 mg/m(2) and epotoside 70 mg/m(2) intraarterially. This FLEOX regimen was repeated every five weeks for two or three courses. Out of the 50 patients,12 malnutritional cases received parenteral and/or enteral nutritional support according to the nutritional condition. Arteriovenous neoadjuvant FLEOX chemotherapy was then administered after the improvement of nutritional state. Their nutritional support methods were adapted to their chemotherapy as well.</p><p><b>RESULTS</b>All the patients' general conditions and symptoms were improved significantly. For the 50 cases, the imageological and histological response rate (CR+PR) was 84.0%, and curative resection rate was 78.0%. Thus, 39 patients underwent subtotal or total gastrectomy, even combined organ resection, with D(2)+alpha or D(3) lymphadenectomy. Despite neoadjuvant chemotherapy, all malnutritional cases had significant weight gain after nutritional support, and other nutritional indexes,such as serum albumin, also resumed to normal.</p><p><b>CONCLUSION</b>Arteriovenous neoadjuvant FLEOX chemotherapy proves favorable therapeutic effect for gastric cancer with advanced abdominal lymph node metastases, and downstages inoperable metastatic lymph nodes for radical operation. This combined modality regimen and nutritional support may play an important role in the treatment of advanced gastric cancer.</p>

Enteral refeeding syndrome after long-term total parenteral nutrition / 中华医学杂志(英文版)

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

Management of tertiary peritonitis in the patients complicated with intestinal fistula / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the etiology and management of tertiary peritonitis in the patients with intestinal fistula.</p><p><b>METHODS</b>One hundred and fifty-three cases of intestinal fistula complicated with tertiary peritonitis were reviewed. The microbiological characteristics, treatment Methods and outcomes were analyzed.</p><p><b>RESULTS</b>There were 114 males and 39 females with a mean age of (42+/- 19) years. The main causes of intestinal fistula included gastrointestinal surgery (40.5%), trauma (31.4%) and severe pancreatitis (14.4%), etc. The most common cultured bacteria of 157 specimens from 79 patients with tertiary peritonitis were Escherichia coli (24.2%), Pseudomonas aeruginosa (12.1%), Staphylococcus aureus (10.8%), Enterobacter cloacae (10.2%), Klebsiella pneumoniae (8.3%). Debridement of the necrotic tissues, drainage of the abscess, continuous rinsing plus negative pressure drainage and antibiotics treatment were performed in 52 cases. Nineteen patients only changed from simple tube drainage to continuous rinsing plus negative pressure drainage. Twenty- eight patients changed to continuous rinsing plus negative pressure drainage and received antibiotics as well. Thirty- six patients received antibiotics and ecoimmune nutrition, while 18 patients only received ecoimmun nutrition.</p><p><b>CONCLUSIONS</b>Intestinal fistula complicated with tertiary peritonitis was mainly caused by residual infectious focus and inappropriate drainage. The rational treatments include reoperation for debridement of the necrotic and infectious tissues, changing drainage to continuous rinsing plus negative pressure drainage, appropriate usage of antibiotics, and ecoimmune nutrition.</p>