Intestinal Decontamination Therapy for Dyskinesia and Motor Fluctuations in Parkinson's Disease

Parkinson's disease is neurodegenerative disorder with an initial robust response to levodopa. As the disease progresses, patients frequently develop dyskinesia and motor fluctuations, which are sometimes resistant to pharmacological therapy. In recent years, abnormalities in gut microbiota have been identified in these patients with a possible role in motor manifestations. Dysbiosis may reduce levodopa absorption leading to delayed “On” or “no-On” states. Among 84 consecutive patients with PD, we selected 14 with levodopa-induced dyskinesia and motor fluctuations with a Movement Disorders Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part IV ≥ 8 points following a trial of pharmacological adjustment 2–3 months prior to study enrollment or adjustments in deep brain stimulation therapy. Patients received treatment with sodium phosphate enema followed by oral rifaximin and polyethylene glycol for 7 and 10 days, respectively. Evaluations between 14 to 21 days after starting treatment showed improvement in MDS-UPDRS-IV (P = 0.001), including duration (P = 0.001) and severity of dyskinesia (P = 0.003); duration of medication “Off”-state (P = 0.004); functional impact of motor fluctuations (P = 0.047) and complexity of motor fluctuations (P = 0.031); no statistical improvement was observed in “Off” dystonia (P = 0.109) and total motor scores (P = 0.430). Marked to moderate improvement in dyskinesia was observed in 57% of cases with blinded evaluation of videos. About 80% of patients perceived moderate to robust improvement at follow-up. A therapeutic strategy aimed at decontamination of intestines showed benefit in motor fluctuations and dyskinesia. Further studies should confirm and clarify the mechanism of improvement observed in these patients.

DIVERTICULAR DISEASE: FROM TRADITION TO INNOVATION

This article presents current data from the world medical literature and a five-year study of surgical clinic on the effect of perioperative intestinal decontamination in patients with acute complicated diverticulitis on the frequency of postoperative complications after elective resection of the sigmoid colon and the formation of primary colorectal anastomosis. The possibility of selective perioperative intestinal decontamination in patients with acute sigmoid diverticulitis complicated by covered perforation, the number of postoperative surgical and general complications was observed. The used scheme of topical antibacterial sanitation, along with orthograde intestinal cleansing with osmolar solutions, significantly reduced the frequency of insufficiency of colectal anastomoses, surgical (abdominal) and the total number of postoperative complications.

LAPAROSCOPIC AND ROBOTIC-ASSISTED SURGERYFOR COMPLICATED DIVERTICU

The article presents the results of a longtime experience with the effects of perioperative intestinal decontamination in patients with complicated diverticulitis on the incidence of postoperative complications following delayed minimally invasive sigmoid colectomy and colorectal anastomosis creation. Purpose. This work aims to evaluate the prophylactic potential of selective perioperative intestinal decontamination in patients with sigmoid diverticulitis due to perforation of the inflamed diverticula, as a form of diverticular disease; to study the incidence of postoperative complications in patients with complicated diverticulitis following laparoscopic and robotic-assisted surgery. Results. Of 179 patients included in the study, 136 (76%) did not develop postoperative complications. In Group A, 11 (12%) of 91 patients and in Group B, 17 (19.3%) of 88 patients developed postoperative complications specific to the type of surgery undertaken. The most common complications included colorectal anastomotic leakage, adhesive intestinal obstruction, anastomotic bleeding, intra-abdominal hemorrhage and localized peritonitis. A statistical comparison revealed no statistically significant differences between the groups studied. 8 (8.8%) of 91 patients in Group A and in 7 (8.0%) of 88 patients in Group B were diagnosed with extra-abdominal (nonsurgical) complications. Thus, the total postoperative complication rate was lower in Group A (n=19 (20.9%) than in Group B (n=24 (27.3%)) (Х2 =1.002, р=0.316). Colorectal anastomotic leakage rates were lower in Group A (n=1 (1.1.%)) than in Group B (n=4 (4.6%)) (F=0.205, p>0.05). Wound infection rates in Group A were 6.6% (n=6) patients and in Group В – 11.3% (n=10) patients (Х2*=6.483, р=0.01). No deaths were reported. CONCLUSION. Selective intestinal decontamination combined with oral decontaminating solutions has been shown to reduce the occurrence of colorectal anastomotic leaks, wound infection, surgical and general postoperative complications.

Effect of selective intestinal decontamination on the incidence of postoperative wound complications and anastomosis insufficiency in colorectal surgery (literature review)

The article provides a literary review of the fundamentals, role in clinical practice, and possibilities of selective perioperative intestinal decontamination. Aspects of prevention of postoperative wound complications and anastomosis insufficiency in colorectal surgery are analyzed. The key point is to reduce the number of certain bacterial strains that contribute to the development of exponential inflammation in the anastomosis zone. Modern schemes for the use of oral decontamination and their combination with intravenous antibiotic prophylaxis for the failure of anastomoses of the left half of the colon and rectum are considered.

SELECTIVE INTESTINAL DECONTAMINATION IN PATIENTS WITH ACUTE DIVERTICULITIS COMPLICATED BY COVERED PERFORATION AS A WAY TO REDUCE THE NUMBER OF POSTOPERATIVE COMPLICATIONS

The effect of selective perioperative intestinal decontamination in patients with acute sigmoid diverticulitis complicated by covered perforation on the number of postoperative complications was described. A prospective and partially retrospective study of the results of complex treatment of 196 patients with acute diverticulitis localized in the sigmoid colon, complicated by covered perforation, divided into group А – 66 patients with perioperative selective intestinal decontamination and group B – 130 patients without decontamination. Rectal resection by open, laparoscopic and robot-assisted methods with the formation of primary colorectal anastomoses was performed in all cases. Of the 196 patients included in our study, 122 (62,2 %) underwent surgery without complications. Abdominal postoperative complications directly caused by surgical interventions and related, according to the classification of Сlavien-Dindo surgical complications (C-D) to grades I, IIIb and IV, were noted in 9 (13,6 %) patients of group A and 36 (27,6 %) patients of group B, and extraabdominal (C-D I, IV), which included: pneumonia, acute renal failure, pyelonephritis, urosepsis, postoperative delirium and transient ischemic attack – in 8 (12,1 %) and 21 (16,1 %) patients of the corresponding groups. In group A, there was a significantly lower number of general abdominal and wound complications, as well as the total number of all postoperative complications (p = 0,03, p = 0,04 and p = 0,0111 respectively). There were no fatalities. The used scheme of oral antibiotic therapy, along with orthograde intestinal sanitation with osmolar solutions, significantly reduced the frequency of surgical and non-surgical complications.