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Diseases of the Colon and Rectum Jan 2023Surgical treatment of recurrent rectovaginal fistulas is notoriously difficult. Placement of the gracilis muscle between the vagina and anus is an advanced technique...
BACKGROUND
Surgical treatment of recurrent rectovaginal fistulas is notoriously difficult. Placement of the gracilis muscle between the vagina and anus is an advanced technique used to close persistent fistulas. We have utilized this procedure for recalcitrant fistulas and hypothesized that a gracilis interposition would offer a good treatment option for patients with refractory rectovaginal fistulas, regardless of underlying etiology.
OBJECTIVE
The purpose of this study was to investigate healing rates of gracilis interposition in patients with refractory rectovaginal fistulas.
DESIGN
Following institutional review board approval, a retrospective review of all adult female patients with a diagnosis of rectovaginal fistula between January 2009 and August 2020 was performed; those who underwent gracilis interposition for definitive fistula closure were included for analysis.
SETTINGS
The study was conducted at a colorectal surgery department at a tertiary center in the United States.
PATIENTS
All patients were adult females with a diagnosis of a rectovaginal fistula who underwent gracilis interposition for definitive closure.
MAIN OUTCOME MEASURES
Patient demographics, etiology of rectovaginal fistula, previous surgical intervention, presence of intestinal diversion, operative details, 30-day morbidity, recurrence of fistula, and time to recurrence. Fistula closure was defined as lack of clinical symptoms following stoma closure, negative fistula detection on gastrograffin enema' and absence of an internal opening at examination under anesthesia.
RESULTS
Twenty-two patients were included who had a median age of 43 years (range, 19-64 years) and median body mass index of 31 kg/m 2 (range, 22-51). Median time between prior attempted surgical repair and gracilis surgery was 7 months (range, 3-17). The number of previously attempted repairs were 1-2 (n = 8), 3-4 (n = 9), and > 4 (n = 5). The most recent attempted surgical repair was rectal advancement flap (n = 7), transperineal +/- Martius flap (n = 4), episioproctotomy (n = 3), transvaginal repair (n = 2), and other (n = 6). All patients had fecal diversion at the time of gracilis surgery. Thirty-day postoperative surgical site infection at the graft/donor site was 32% (n = 7). At a median follow-up of 22 months (range 2-62), fistula closure was 59% (n = 13). Gracilis interposition was successful in all inflammatory bowel disease patients.
LIMITATIONS
The study was limited by its retrospective nature.
CONCLUSIONS
Gracilis interposition is an effective operative technique for reoperative rectovaginal fistula closure. Patients should be counseled regarding the possibility of graft/donor site infection. See Video Abstract at http://links.lww.com/DCR/B763 .
REPARACIN CON COLGAJO DE GRACILIS PARA LA FSTULA RECTOVAGINAL REOPERATORIA
ANTECEDENTES:El tratamiento quirúrgico de las fístulas rectovaginales recurrentes es muy difícil. La colocación del músculo gracilis entre la vagina y el ano es una técnica avanzada que se utiliza para cerrar las fístulas persistentes. Hemos utilizado este procedimiento para las fístulas recalcitrantes y planteamos la hipótesis de que una interposición del gracilis ofrecería una buena opción de tratamiento para pacientes con fístulas rectovaginales refractarias, independientemente de la etiología subyacente.OBJETIVO:Investigar las tasas de curación de la interposición del gracilis en pacientes con fístulas rectovaginales refractarias.DISEÑO:Tras la aprobación de la junta de revisión institucional, se realizó una revisión retrospectiva de todas las pacientes adultas con un diagnóstico de fístula rectovaginal entre enero de 2009 y agosto de 2020; los que se sometieron a interposición de gracilis para el cierre definitivo de la fístula se incluyeron para el análisis.AJUSTE:Departamento de cirugía colorrectal de un centro terciario en Estados Unidos.PACIENTES:Todas las pacientes adultas con diagnóstico de fístula rectovaginal que se sometieron a interposición de gracilis para cierre definitivo.PRINCIPALES MEDIDAS DE RESULTADO:datos demográficos del paciente, etiología de la fístula rectovaginal, intervención quirúrgica previa, presencia de derivación intestinal, detalles quirúrgicos, morbilidad a los 30 días, recurrencia de la fístula y tiempo hasta la recurrencia. El cierre de la fístula se definió como la ausencia de síntomas clínicos después del cierre del estoma, la detección negativa de la fístula en el enema de gastrograffin y la ausencia de una abertura interna en el examen bajo anestesia.RESULTADOS:Se incluyeron 22 pacientes que tenían una mediana de edad de 43 años (rango 19-64 años) y una mediana de índice de masa corporal de 31 kg / m2 (rango 22-51). La mediana de tiempo entre el intento previo de reparación quirúrgica y la cirugía del gracilis fue de 7 meses (rango 3-17). El número de reparaciones previamente intentadas fue: 1-2 (n = 8), 3-4 (n = 9), y >4 (n = 5). El intento de reparación quirúrgica más reciente fue el colgajo de avance rectal (n = 7), el colgajo transperineal +/- Martius (n = 4), la episioproctotomía (n = 3), la reparación transvaginal (n = 2) y otros (n = 6). Todos los pacientes tenían derivación fecal en el momento de la cirugía gracilis. La infección del sitio quirúrgico posoperatorio a los 30 días en el sitio del injerto / donante fue del 32% (n = 7). Con una mediana de seguimiento de 22 meses (rango 2-62), el cierre de la fístula fue del 59% (n = 13). La interposición de Gracilis fue exitosa en todos los pacientes con enfermedad inflamatoria intestinal.LIMITACIONES:Carácter retrospectivo de los datos.CONCLUSIONES:La interposición de Gracilis es una técnica quirúrgica eficaz para el cierre reoperatorio de la fístula rectovaginal. Se debe asesorar a los pacientes sobre la posibilidad de infección del sitio del injerto / donante. Consulte Video Resumen en http://links.lww.com/DCR/B763 . (Traducción-Dr. Ingrid Melo ).
Topics: Adult; Humans; Female; Young Adult; Middle Aged; Retrospective Studies; Rectovaginal Fistula; Diatrizoate Meglumine; Rectal Fistula; Anal Canal; Vaginal Fistula
PubMed: 34759248
DOI: 10.1097/DCR.0000000000002249 -
Animal Cells and Systems 2021Constipation is a common disease that reduces life quality. Drugs of various mechanisms are being developed to resolve this affliction. Intestinal motility can be easily...
Constipation is a common disease that reduces life quality. Drugs of various mechanisms are being developed to resolve this affliction. Intestinal motility can be easily monitored in zebrafish, and so we selected this organism to develop a constipation model to measure drug-induced prokinetic effects. In this study, intestinal motility was monitored in zebrafish by tracking intestinal transit using fluorescence, after which an opioid-induced constipation model was established using loperamide. We then evaluated the prokinetic effect of diatrizoate meglumine (Gastrografin®), which has been empirically used to treat post-operative ileus or adhesive small bowel obstructions. Diatrizoate meglumine was effective in promoting bowel movements in an opioid-induced zebrafish constipation model and its prokinetic effect was associated with an increased expression of interstitial cells of Cajal (ICC) markers. Therefore, the loperamide-induced zebrafish constipation model developed herein is a promising tool to evaluate novel constipation therapies.
PubMed: 34745433
DOI: 10.1080/19768354.2021.1991472 -
The American Surgeon Apr 2022The advent of the Gastrograffin® small bowel follow through (G-SBFT) has resulted in a decreased rate of operative intervention of small bowel obstructions (SBO);...
INTRODUCTION
The advent of the Gastrograffin® small bowel follow through (G-SBFT) has resulted in a decreased rate of operative intervention of small bowel obstructions (SBO); however, there is no data to suggest when G-SBFT should be performed.
METHODS
We retrospectively reviewed 548 patients, admitted to 1 of 9 hospitals with a diagnosis of SBO. Patients were divided into two categories with regards to timing of G-SBFT: before (early) or after (late) 48 hours from admission. Primary outcomes were length of stay (LOS) and total cost. Secondary outcomes were operative interventions and mortality.
RESULTS
Of the reviewed patients, 71% had the G-SBFT ordered early. Comparing early versus late, there were no differences in patient characteristics with regards to age, sex, or BMI. There was a significant difference between LOS (4 vs 8 days, < 0.05) and total cost ($17,056.19 vs $33,292.00, < 0.05). There was no difference in mortality (1.3% vs 2.6%, = 0.239) or 30-day readmission rates (15.6% vs 15.9%, = 0.509). Patients in the early group underwent fewer operations (20.7% vs 31.9%, = 0.05).
DISCUSSION
Patients that had a G-SBFT ordered early had a decreased LOS, total cost, and operative intervention. This suggests there is a benefit to ordering G-SBFT earlier in the hospital stay to reduce the overall disease burden, and that it is safe to do so with regards to mortality and readmissions. We therefore recommend ordering a G-SBFT within 48 hours to reduce LOS, cost, and need for an operation.
Topics: Diatrizoate; Diatrizoate Meglumine; Humans; Intestinal Obstruction; Intestine, Small; Length of Stay; Retrospective Studies
PubMed: 34732062
DOI: 10.1177/00031348211050823 -
Journal of Radiation Research Jan 2022Oral administration of a water-soluble iodine contrast agent (gastrografin) was reported to assist in the appropriate contouring of the small intestine on computed...
Oral administration of a water-soluble iodine contrast agent (gastrografin) was reported to assist in the appropriate contouring of the small intestine on computed tomography (CT)-based radiotherapy (RT) planning. The efficacy and optimal dose of gastrografin in CT-based image-guided brachytherapy (IGBT) for cervical cancer remain unknown. This study aimed to investigate the efficacy of pretreatment oral administration of gastrografin at a small dose of 50 ml in CT-based IGBT for cervical cancer. A total of 422 sessions in 137 patients who underwent CT-based IGBT with 50 ml of oral gastrografin (concentration, 3% or 4%) were analyzed. Preparation of gastrografin was judged as effective when the small intestine was contrast-enhanced at the area where the small intestine was in contact with the uterus/adnexa. About 287 out of 422 sessions (68%) were judged as effective with gastrografin preparation. The 135 ineffective sessions were considered as follows: (i) the contrast enhancement of the small intestine was not confirmed (n = 36), (ii) the small intestine was not in contact with the uterus/adnexa despite the confirmation of the contrast enhancement of the small intestine (n = 34), and (iii) gastrografin was absent in the small intestine at the area in contact with the uterus/adnexa, even when gastrografin was observed in the small intestine at the area not in contact with the uterus/adnexa (n = 65). In conclusion, pretreatment oral administration of a small dose gastrografin achieved moderate efficacy for accurate contouring of the small intestine close to the uterus/adnexa in CT-based IGBT for cervical cancer.
Topics: Brachytherapy; Contrast Media; Diatrizoate Meglumine; Female; Humans; Tomography, X-Ray Computed; Uterine Cervical Neoplasms
PubMed: 34718687
DOI: 10.1093/jrr/rrab102 -
Journal of Gastroenterology and... Jan 2022We had previously reported that the administration of Gastrografin through a nasogastric tube (NGT-G) followed by long tube (LT) strategy could be a novel standard... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
We had previously reported that the administration of Gastrografin through a nasogastric tube (NGT-G) followed by long tube (LT) strategy could be a novel standard treatment for adhesive small bowel obstruction (ASBO); however, the long-term outcomes after initial improvement remain unknown. This study aimed to analyze the long-term outcomes of first-line NGT-G.
METHODS
Enrolled patients with ASBO were randomly assigned to receive LT or NGT-G between July 2016 and November 2018. Thereafter, the cumulative surgery rate, cumulative recurrence rate, and overall survival (OS) rate were analyzed. In addition, subset analysis was conducted to determine the cumulative recurrence rate according to colonic contrast with Gastrografin at 24 h.
RESULTS
A total of 223 patients (LT group, n = 111; NGT-G group, n = 112) were analyzed over a median follow-up duration of 550 days. The cumulative 1-year surgery rates, cumulative 1-year recurrence rates, and 1-year OS rates in the LT and NGT-G groups were 18.8% and 18.1%, 30.0% and 31.7%, and 99.1% and 96.6%, respectively; no significant differences were observed between both groups. In the NGT-G group, a negative colonic contrast at 24 h demonstrated a higher tendency for future recurrence compared with a positive colonic contrast at 24 h (1-year recurrence rate: negative contrast, 46.9% vs positive contrast, 27.6%).
CONCLUSIONS
Gastrografin through a nasogastric tube followed by LT can be a promising treatment strategy for ASBO, with long-term efficacies equivalent to initial LT placement.
Topics: Contrast Media; Diatrizoate Meglumine; Humans; Intestinal Obstruction; Intestine, Small; Intubation, Gastrointestinal; Tissue Adhesions; Treatment Outcome
PubMed: 34478173
DOI: 10.1111/jgh.15681 -
The Journal of International Medical... Jun 2021The post-operative complication of chylous leakage after breast cancer is relatively rare, and few clinical studies have been published. We report a 64-year-old woman...
The post-operative complication of chylous leakage after breast cancer is relatively rare, and few clinical studies have been published. We report a 64-year-old woman with chylous leakage following modified radical mastectomy. We describe the patient's diagnostic and treatment process in detail. The patient was diagnosed with grade II (left) breast invasive ductal carcinoma. Post-operatively, the patient's chest wall and axilla were pressurized, and negative pressure drainage was initiated. On the fifth post-operative day, the drainage from the chest wall and axilla increased significantly, and the patient developed chylous leakage on the eighth postoperative day. We injected meglumine diatrizoate (100 mL) and elemene (10 mL) into the patient's axilla, and the chylous leakage gradually resolved 18 days post-operatively. In this report, we focus on managing a case of chylous leakage after modified radical mastectomy for breast cancer. Meglumine diatrizoate combined with elemene is a possible treatment for the management of this rare complication.
Topics: Axilla; Breast Neoplasms; Female; Humans; Lymph Node Excision; Mastectomy; Mastectomy, Modified Radical; Middle Aged
PubMed: 34130539
DOI: 10.1177/03000605211021375 -
Khirurgiia 2021To improve the outcomes of therapy of acute adhesive small bowel obstruction via development of a comprehensive management including CT, deep endoscopy-assisted...
OBJECTIVE
To improve the outcomes of therapy of acute adhesive small bowel obstruction via development of a comprehensive management including CT, deep endoscopy-assisted nasointestinal drainage of small bowel with injection of a water-soluble contrast.
MATERIAL AND METHODS
There were 128 patients with acute adhesive small bowel obstruction for the period from 2015 to 2018. The study included 2 groups of patients depending on therapeutic approach and duration of treatment. In the first group, conventional approach for acute adhesive small bowel obstruction was applied. Upon admission, all patients with confirmed acute adhesive small bowel obstruction underwent gastric intubation for decompression of the upper gastrointestinal tract. Barium sulfate injection followed by X-ray examination was performed to assess an effectiveness of therapy. In the second group, computed tomography was performed in addition to X-ray examination and ultrasound. Moreover, conservative treatment included deep endoscopy-assisted nasointestinal drainage and subsequent administration of a water-soluble contrast in addition to traditional approaches.
RESULTS
Therapy was effective in 99 (71.2%) patients; 39 (28.8%) ones required surgery. Deep endoscopy-assisted nasointestinal drainage with injection of a water-soluble contrast was effective in 45 (78.9%) patients. Overall mortality in traditional approach was 1.4%, postoperative mortality - 3.7%. There were no lethal outcomes in case of a new approach.
CONCLUSION
Deep endoscopy-assisted nasointestinal drainage with injection of a water-soluble contrast is the most effective therapeutic method for acute adhesive small bowel obstruction (78.9%). These findings can significantly improve treatment outcomes in these patients.
Topics: Adhesives; Conservative Treatment; Contrast Media; Diatrizoate Meglumine; Humans; Intestinal Obstruction; Intestine, Small; Tissue Adhesions
PubMed: 34029035
DOI: 10.17116/hirurgia202106145 -
Journal of Pediatric Surgery Jul 2021therapeutic strategy for meconium-related ileus (MRI) in very-low-birth-weight infants (VLBWs) has not been established. This study aims to clarify the optimum...
BACKGROUND/PURPOSE
therapeutic strategy for meconium-related ileus (MRI) in very-low-birth-weight infants (VLBWs) has not been established. This study aims to clarify the optimum therapeutic strategy for MRI in VLBWs.
METHODS
MRI was defined as delayed meconium excretion and microcolon on contrast enema with Gastrografin (diatrizoate acid). Forty-two infants with MRI were treated at our institution between 2009 and 2019, and are reviewed here. They were classified into two groups: in group A (n=21), Gastrografin regurgitated into the dilated intestine during the first or second round of Gastrografin enema (GaE), while in group B (N = 21), Gastrografin did not regurgitate. Laparotomy was indicated if the intestine was perforated, or if abdominal distention was not relieved by two rounds of GaE.
RESULTS
in group A, meconium was excreted in all cases within 24 h after GaE, and no cases required laparotomy. In group B, twelve cases (57%) underwent laparotomy (P < 0.01), six cases in this group (29%), showed free air on X-ray images (P < 0.01). The median hospital stay in groups A and B were 89.0 and 136.5 days, respectively (P < 0.05). Overall mortality was 2.4%.
CONCLUSIONS
early therapeutic diagnosis by GaE followed by early surgery is suggested as the optimum strategy for MRI in VLBWs.
Topics: Diatrizoate Meglumine; Enema; Humans; Ileus; Infant, Newborn; Infant, Very Low Birth Weight; Intestinal Obstruction; Meconium; Meconium Ileus
PubMed: 33896618
DOI: 10.1016/j.jpedsurg.2021.03.029 -
Dento Maxillo Facial Radiology Oct 2021To evaluate the diagnostic accuracy using sodium iodide (NaI) and dimethyl sulfoxide (DMSO) as contrast agent in cone beam computed tomography (CBCT) scanning, and...
OBJECTIVES
To evaluate the diagnostic accuracy using sodium iodide (NaI) and dimethyl sulfoxide (DMSO) as contrast agent in cone beam computed tomography (CBCT) scanning, and compare this with micro-CT.
METHODS
18 teeth were cracked artificially by soaking them cyclically in liquid nitrogen and hot water. After pre-treatment with artificial saliva, the teeth were scanned in four modes: CBCT routine scanning without contrast agent (RS); CBCT with meglumine diatrizoate (MD) as contrast agent (ES1); CBCT with NaI + DMSO as contrast agent (ES2); and micro-CT (mCT). The number of crack lines was evaluated in all four modes. Depth of crack lines and number of cracks presented from the occlusal surface to the pulp cavity (Np) in ES2 and micro-CT images were evaluated.
RESULTS
There were 63 crack lines in all 18 teeth. 45 crack lines were visible on ES2 images as against four on the RS and ES1 images (0.05) and 37 on micro-CT images (0.05). Further, 34 crack lines could be observed on both ES2 and micro-CT images, and the average depth presented on ES2 images was 4.56 ± 0.88 mm and 3.89 ± 1.08 mm on micro-CT images (0.05). More crack lines could be detected from the occlusal surface to the pulp cavity on ES2 images than on micro-CT images (22 11).
CONCLUSION
CBCT with NaI +DMSO as the contrast agent was equivalent to micro-CT for number of crack lines and better for depth of crack lines. NaI + DMSO could be a potential CBCT contrast agent to improve diagnostic accuracy for cracked tooth.
Topics: Cone-Beam Computed Tomography; Cracked Tooth Syndrome; Humans; Spiral Cone-Beam Computed Tomography; Tooth Fractures; X-Ray Microtomography
PubMed: 33877874
DOI: 10.1259/dmfr.20210003 -
Surgery Aug 2021Gastrografin challenge is increasingly used as a diagnostic tool to predict patients who may benefit from nonoperative management in adhesive small bowel obstruction....
BACKGROUND
Gastrografin challenge is increasingly used as a diagnostic tool to predict patients who may benefit from nonoperative management in adhesive small bowel obstruction. This study explores the optimal timing of Gastrografin in the management of adhesive small bowel obstruction by comparing early versus late Gastrografin challenge.
METHODS
A retrospective chart review from January 2016 to January 2018 identified patients with adhesive small bowel obstruction who underwent Gastrografin challenge. A receiver operating characteristic curve, to predict a duration of stay less than 5 days, calculated a 12-hour limit which separated early and late groups. Nonoperative and operative patients were compared separately. Our primary outcome was duration of stay. Secondary outcomes included operative requirement, time to the operating room, complication rate, and 1-year mortality. In a separate analysis, multivariable logistic regression identified independent risk factors for 1-year mortality.
RESULTS
One hundred thirty-four patients were identified (58 early, 76 late). In nonoperative patients, the early group had a shorter duration of stay (3.2 days vs 5.4 days), fewer complications, and a lower complication and 1-year mortality rate (P < .05). In operative patients, the early group had a shorter preoperative duration of stay (1.8 days vs 3.9 days) (P < .05). On multivariable regression, congestive heart failure, any postoperative complication, and operative requirement were the best predictors of 1-year mortality (R2 = 0.321; P < .05).
CONCLUSION
Gastrografin administration within 12 hours of adhesive small bowel obstruction diagnosis had favorable outcomes in terms of duration of stay, complications, and mortality in nonoperative patients. Moreover, in operative patients, preoperative duration of stay was shortened. Our findings suggest protocolizing early Gastrografin challenge may be an important principle in adhesive small bowel obstruction management.
Topics: Aged; Aged, 80 and over; Contrast Media; Diatrizoate Meglumine; Drug Administration Schedule; Female; Humans; Intestinal Obstruction; Intestine, Small; Length of Stay; Male; Middle Aged; Patient Selection; Predictive Value of Tests; ROC Curve; Retrospective Studies; Tissue Adhesions; Tomography, X-Ray Computed
PubMed: 33836900
DOI: 10.1016/j.surg.2021.03.008