O37 CONCOMITANT INTESTINAL RESECTION DOES NOT NEGATIVELY INFLUENCE LONG TERM OUTCOMES FOLLOWING COMPLEX ABDOMINAL WALL RECONSTRUCTION

Aim Simultaneous intestinal resection increases infective risks following abdominal wall reconstruction. We investigated the frequency of those risks and its impact on long-term outcomes. Material and Methods Analysis of prospectively accrued data from patients undergoing AWR by a single surgeon (01/01/2014–31/12/2020). Comparison between AWR with (IR-AWR) and without (AWR) concomitant intestinal resection. Clinical review was undertaken 6 monthly for 24 months with ongoing telephone follow-up thereafter. Results 101 repairs were performed within the study period (46 AWR,55 IR-AWR). IR-AWR patients underwent 129 gastrointestinal procedures including 30 gastrointestinal fistula,33 small bowel,19 colonic and 2 gastric resections. Both groups were similar in terms of smoking status, diabetes, but obesity (BMI>30) was more prevalent in AWR(23/46(50%)vs.16/55(29%); p=0.03). Hernia defects were the same for both groups; AWR median area (range) 511cm2(47–2171 cm2) and IR+AWR 471cm2(50–2827cm2) (p = 0.7). Post-operative wound infection was more frequent following IR-AWR (20/55(36%) (Superficial incisional=13,deep incisional=6, cavity=1) vs. 6/46(13%)(N = 5,0,1 respectively);Odds ratio(OR)=3.8 (95% CI1.4-10.6); p=0.01). Patients undergoing IR-AWR were also more likely to experience ileus necessitating short-term postoperative parenteral nutrition (OR 3.3(1–10.8); p=0.05) and Clavien Dindo>2 complications (OR4.4 (1.2–16.7); p=0.03). Within IR-AWR cohort there was a single anastomotic complication requiring re-laparotomy and one mesh infection treated with antibiotics. Median follow-up= 25.2 months(range 1.2–88.8). 14 patients died during follow-up (AWR 7/46(15%), IR-AWR 7/55(13%); p=0.7). 5 were lost to follow-up (3AWR, 2 IR-AWR). 12(26%) AWR and 8(15%) IR-AWR reported either persistent or delayed onset chronic abdominal wall pain post repair(P = 0.14). Recurrent hernias occurred in 7/46(15%) AWR compared with 10/55(18%)IR-AWR(p = 0.5). Conclusions Despite more frequent short-term complications in IR-AWR patient outcomes are comparable at 2 years.

Cases of gastro-colonic fistula due to postoperative peptic ulcer of the jejunum

The issue I have touched upon has already been repeatedly debated on the pages of the medical press in order to clarify the method of surgical intervention for severe complications of such a relatively safe operation as the imposition of a gastrointestinal fistula for gastric ulcer and duodenal ulcer.

Immune enhancement to prevent infected pancreatic necrosis: A double-blind randomized controlled trial

BACKGROUND&AIMS Infected pancreatic necrosis (IPN) is a highly morbid complication of acute pancreatitis(AP). Since there is evidence of immunosuppression in the early phase of AP, immune enhancement using Thymosin alpha 1 (Tα1), which stimulates both innate and adaptive immunity, may be a therapeutic strategy to prevent IPN. Our aim was to assess the efficacy of early Tα1 treatment on the development of IPN. METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled trial in patients with predicted severe acute necrotizing pancreatitis (ANP). ANP patients with an APACHE II score≥8 admitted within seven days of the advent of symptoms were considered eligible. Enrolled patients were assigned to receive a subcutaneous injection of Tα1 1.6 mg, every 12 hours for the first 7 days and 1.6 mg once a day for the subsequent 7 days or matching placebo (normal saline). The primary outcome was the development of IPN during the index admission. RESULTS From Mar 2017 through Dec 2020, 508 patients were randomized at 16 hospitals, of whom 254 were assigned to receive Tα1 and 254 placebo. During the index admission, 40/254 (15.7%) patients in the Tα1 group developed IPN compared with 46/254 patients (18.1%) in the placebo group (difference -2.4% [95%CI -7.4% to 5.0%]; p=0.47). The results were similar in four predefined subgroups. There was no difference in other major complications, including new-onset organ failure (10.6% vs. 15.0%; p=0.15), bleeding (6.3% vs. 3.5%; p=0.15), and gastrointestinal fistula (2.0% vs. 2.4%; p=0.75) during the index admission. CONCLUSIONS The immune-enhancing Tα1 treatment of patients with predicted severe ANP did not reduce the incidence of IPN during the index admission.

Clinical guidelines for the management of gastrointestinal fistula – developed by experts of the Polish Surgical Society

Introduction: Gastrointestinal fistula is one of the most difficult problems in gastrointestinal surgery. It is associated with high morbidity and mortality, numerous complications, prolonged hospitalization, and high cost of treatment. </br>Aim: This project aimed to develop recommendations for the treatment of gastrointestinal fistulas, based on evidence-based medicine and best clinical practice to reduce treatment-related mortality and morbidity. </br>Material and methods: The preparation of these recommendations is based on a review of the literature from the PubMed, Medline, and Cochrane Library databases from 1.01.2010 to 31.12.2020, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations in the form of a directive were formulated and assessed using the Delphi method. </br>Results and conclusions: Nine recommendations were presented along with a discussion and comments of experts. Treatment should be managed by a multidisciplinary team (surgeon, anesthetist, clinical nutritionist/dietician, nurse, pharmacist, endoscopist).

RECTAL FISTULA

Свищи желудочно-кишечного тракта являются наиболее тяжелым осложнением различных оперативных вмешательств на брюшной полости, несущим угрозу для жизни больного. На сегодняшний день прямокишечные свищи являются одной из часто встречающих заболеваний в структуре хирургических заболеваний. Затрагивает данная патология в среднем пациентов в возрасте 30-50 лет, что обуславливает социально-экономическую значимость данной проблемы. На основании изученных исследований и метаанализов, мы можем сказать, что не разработан «золотой стандарт» лечения сложных прямокишечных свищей без осложнений. A gastrointestinal fistula is the most severe complication of various surgical interventions after abdominal surgery, posing a threat to the patient's life. To date, rectal fistulas are one of the most common surgical diseases. This pathology affects on average patients aged 30-50 years, which determines the socio-economic significance of this problem. Based on research and meta-analyzes, we can say that there is no "gold standard" for the treatment of complex rectal fistulas without complications.

Colon Adenocarcinoma Metastasis Through Ileocolic Fistula to Small Bowel in the Setting of Crohn’s Disease

Purpose: Patients with Crohn’s disease (CD) are at higher risk of developing colorectal cancer (CRC) and gastrointestinal fistula. We report an unusual case of sigmoid colon adenocarcinoma in a CD patient that metastasized to the small bowel through an ileocolic fistula tract.Methods: This case report was written after patient was seen in the clinic and reviewing overall hospitalization including clinically relevant data including imaging and pathology reports associated to our focus and presentation. Prior cases of metastatic CRC via fistula tract were reviewed and compared as well. Results: We described an unprecedented case of a sigmoid adenocarcinoma metastasized to ileum via ileal-sigmoid fistula. Patient received surgical treatment and systemic chemotherapy and currently in remission. Conclusion: CD is associated with a higher risk of fistula development. Few cases in the past described CRC metastasized within the gastrointestinal tract through a fistula. Intriguingly in our case, sigmoid adenocarcinoma developed and further metastasized to the ileum via the ileal-sigmoid fistula in the setting of CD. In addition to presenting a unique pathological phenomenon in these patients, this case raises awareness of the importance of regular follow-up and early initiation of IBD therapies.

Gemox chemotherapy in combination with anti-PD1 antibody toripalimab and lenvatinib as first-line treatment for advanced intrahepatic cholangiocarcinoma: A phase 2 clinical trial.

4094 Background: The outcome of advanced intrahepatic cholangiocarcinoma (ICC) remains poor with current gemcitabine-based chemotherapy. This study is to evaluate the safety and efficacy of anti-PD1 agent toripalimab, lenvatinib in combination with oxaliplatin and gemcitabine (Gemox) chemotherapy. Methods: Locally advanced or metastatic ICC patients (pts) were given 240 mg toripalimab Q3W via intravenous (IV) infusion, 8 mg lenvatinib QD orally, and 1g/m² gemcitabine on Day 1 and Day 8, and 85 mg/m² oxaliplatin Q3W by IV for 6 cycles. The primary outcome was objective response rate (ORR), which was evaluated according to RECIST v1.1. Secondary outcomes included safety, progression-free survival (PFS) and overall survival (OS). Treatment would be terminated by confirmed disease progression, unacceptable toxicity, or voluntary withdrawal. Whole exome sequencing was performed on available tumor tissues and PD-L1 expression was determined by immunohistochemistry staining. Results: From May 2019 to Oct 2019, 30 pathologically-confirmed advanced ICC pts with a mean age of 56.5 (range, 25-73) years, including 11 women (37%), were enrolled at Zhongshan Hospital, Fudan University (one pt withdrawn). At the end of last follow-up (February 1, 2021), the ORR was 80% (24/30; 95% CI: 61.4%-92.3%), and disease control rate (DCR) was 93.3% (28/30; 95% CI:77.9%-99.2%). Median follow-up was 16.6 months. One pt achieved complete response (CR). Three pts with locally advanced disease were down-staged and then underwent resection. They remained disease-free survival at the end of last follow-up. 23 pts experienced disease progression and 12 pts (including one pt withdrawn) have died. The median PFS was 10.0 months and median duration of response (DOR) was 9.8 months. The median OS have not been reached. 12-months OS rate was 73.3% (95% CI: 57.5%-89.2%). No grade 5 adverse event (AE) was observed in present study. Grade 3 or 4 neutropenia and thrombocytopenia observed in 3 (10%) and 1 (3.3%) patient, respectively. Non-hematological toxic effects were jaundice (10 %), rash (6.7 %), proteinuria (6.7 %), increased AST level (3.3%), vomiting (3.3%), upper gastrointestinal hemorrhage (3.3%), sepsis (3.3%), gastrointestinal fistula (3.3%), adrenocortical insufficiency (3.3%), interstitial pneumonia (3.3%), and hyponatremia (3.3%). High ORR was significantly associated with positive PD-L1 expression ( p= 0.048) and DNA damage repair (DDR)-related mutations ( p= 0.022) in tumor samples. Conclusions: Gemox chemotherapy in combination with Anti-PD1 antibody Toripalimab and Lenvatinib provided remarkable efficacy with reasonable tolerability in advanced ICC patients. These findings warrant further validation in a large randomized clinical trial. Clinical trial information: NCT03951597.

Double Pylorus in Upper Gastrointestinal Bleeding

Double pylorus, also known as acquired double pylorus, is a rare condition defined as a gastrointestinal fistula connecting stomach antrum and duodenal bulb. The prevalence of double pylorus ranges from 0.001 to 0.4% by esophagogastroduodenoscopy (EGD). Although the etiology is unknown, the formation of double pylorus is related to Helicobacter pylori infection and the use of non-steroidal anti-inflammatory drugs (NSAID). The development of the occurrence of double pylorus is still unknown, but many systemic diseases play a role. We present the case of a 59-year-old man who was admitted to Dr. Soetomo General Hospital with hematemesis and melena. The patient had a history of diabetes mellitus since 3 years and consumption of medicinal herbs for myalgia, which was suspected of NSAIDs for the past 5 months. The patient had anemia with hemoglobin at 8.3 g/dL, enterogenous azotemia with blood urea nitrogen 28 mg/dL and serum creatinine 1.14 mg/dL. At EGD, double pylorus was found and accompanied by gastric ulcer, a giant white base ulcer, part of it covered by clotting without any sign of active bleeding. Biopsy revealed chronic inactive gastritis, and no H. pylori was found. Treatment mainly depends on gastrointestinal acid suppression through a proton pump inhibitor (PPI). The patient was given a high-dose PPI and a mucosal protective agent. He was treated for 1 week and had improved complaints.