Feasibility and Safety of Stentless Uretero-Intestinal Anastomosis in Radical Cystectomy with Ileal Orthotopic Neobladder

Background: We evaluated the feasibility and safety of stentless uretero-intestinal anastomosis (UIA) during radical cystectomy (RC) with an ileal orthotopic neobladder. Methods: We retrospectively reviewed 403 patients who underwent RC for bladder cancer between August 2014 and December 2018. The primary objective was to study the effect of stentless UIA on uretero-intestinal anastomosis stricture (UIAS), and the secondary objective was to evaluate the association between stentless UIA and other complications, including paralytic ileus, febrile urinary tract infection (UTI), and urine leakage. Kaplan–Meier survival analysis was used to estimate UIAS-free survival, and Cox proportional hazard models were applied to identify factors associated with the risk of UIAS. Results: Among 403 patients with 790 renal units, UIAS was identified in 39 (9.7%) patients and 53 (6.7%) renal units. Forty-four (83.0%) patients with UIAS were diagnosed within 6 months. The 1- and 2-year overall UIAS-free rates were 93.9% and 92.7%, respectively. Paralytic ileus was identified in 105 (26.1%) patients and resolved with supportive treatment. Febrile UTI occurred in 57 patients (14.1%). However, there was no leak of the UIA. Conclusions: Stentless UIA during RC with an ileal orthotopic neobladder is a feasible and safe surgical option. Further prospective randomized trials are required to determine the clinical usefulness of stentless UIA during RC.

Reactive Enteric Glial Cells Participate in Paralytic Ileus by Damaging Nitrergic Neurons During Endotoxemia

BackgroundParalytic ileus is common in patients with septic shock, which may cause high morbidity and mortality. Enteric neurons and enteric glial cells (EGCs) participate in the regulation of intestinal motility, but little is known about their role. We aimed to prove whether reactive EGCs have harmful effects on enteric neurons during endotoxemia and lead to intestinal motility disorder in mice. MethodsIn this study, lipopolysaccharide (LPS) was used to induce endotoxemia in mice, and intraperitoneal injections of fluorocitrate (FC) twice per day (9 AM and 6 PM) for 7 days before LPS injections to prevent the activation of EGCs. The effects of reactive EGCs on intestinal motility were analyzed by motility assays in vivo and colonic migrating motor complexes (CMMCs) in vitro. The changes of enteric neurons were evaluated by immunofluorescent staining HuCD, nNOS, CHAT, and TUNEL.ResultsThe expression of glial fibrillary acidic protein (GFAP) was significantly upregulated in LPS-injected animals, indicating EGCs were transformed into a reactive state. The administration of FC could significantly prevent it. Meanwhile, inhibition of reactive EGCs can improve intestinal motility and peristaltic reflex. The density of the general neuronal population (HuC/D-immunoreactive) in the colonic myenteric plexus was significantly increased after suppressing reactive EGCs. The population of nNOS neurons was increased significantly, but there was no significant difference in the number of ChAT neurons. Furthermore, the apoptotic rate of enteric neurons significantly increased, when incubated with the conditional medium of reactive EGCs in vitro. At the same time, the dendritic complexity and the number of primary neuritis neurons were significantly reduced.ConclusionReactive enteric glial cells participated in paralytic ileus by damaging nitrergic neurons during endotoxemia. It may provide a novel therapeutic strategy for intestinal motility disorders during endotoxemia or sepsis.

Paradoxical refractory hypotension following adrenaline administration in a patient taking clozapine

Clozapine is a potent antipsychotic commonly used for refractory schizophrenia. Adverse effects are well recognised including constipation, intestinal obstruction, agranulocytosis and cardiomyopathy. We present a case of paradoxical refractory hypotension following epinephrine administration in a patient taking clozapine. A psychiatric inpatient who had been taking clozapine for many years developed paralytic ileus and obstruction requiring surgical intervention. Following initiation of epinephrine administration intraoperatively he developed refractory hypotension which improved only when epinephrine was weaned off. This effect is likely due to uninterrupted β2-agonist activity in the presence of clozapine-induced α-blockade. Clinicians need to have greater awareness of this serious interaction and avoid the use of epinephrine in patients taking clozapine.

Deep Learning Model for Mortality Prediction of ICU Patients with Paralytic Ileus

BackgroundParalytic Ileus (PI) patients in the Intensive Care Unit (ICU) are at a significant risk of death. Prediction of at-risk patients for mortality after 24 hours of admission of ICU PI patients is important to increase the life expectancy of PI patients.Methods and ResultsThe proposed framework, DLMP (Deep Learning Model for Mortality Prediction of ICU Patients with PI) is a powerful deep learning model consisting of six total unique clinical lab items and two demographics as inputs to a Neural Network(NN) of only two neuron layers. Using the Medical Information Mart for Intensive Care III (MIMIC-III) dataset of 1,017 ICU PI patients, the DLMP resulted in the best prediction performance with an AUC score of 0.866.ConclusionThe proposed approach is capable of modeling the mortality of ICU patients after 24 hours admission using only six unique total clinical data and two demographics with a simple NN architecture. DLMP framework significantly improves the outcome prediction compared to the process mining and machine learning models. The proposed DLMP has the potential of allowing clinicians to create targeted interventions that reduce mortality for PI patients in an ICU setting.

Gluteal muscle damage and rhabdomyolysis after olanzapine poisoning: a case report

Olanzapine is a widely adopted atypical antipsychotic medication used to manage schizophrenia. Reports show that the incidence rate of adverse reactions to olanzapine is significantly lower than those of other classic antipsychotic medications. However, olanzapine overdose may be associated with severe consequences. Herein, we report a 21-year-old female patient who had taken nearly 700 mg (70 tablets) of olanzapine; she was found after 30 hours. As her condition progressed, she presented with rhabdomyolysis, swelling in the thighs and hips, paralytic ileus, digestive tract hemorrhage, and elevated serum amylase and lipase levels; notably, she recovered after treatment. This intractable case is of great clinical significance and suggests that early-phase hemoperfusion plays a critical role in olanzapine poisoning-related rhabdomyolysis.

Complications of Ovarian Cancer Surgery in Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta

Background: Ovarian cancer remains as one of the deadliest gynecologic problems globally. Often appears in advanced state, its surgery proves to be a challenge for clinicians. This study aim to present complications surrounding ovarian cancer surgery.Methods: This study was a cross-sectional study to analyze reports of intraoperative and postoperative complications in ovarian cancer patients undergoing laparotomy in Dr. Cipto Mangunkusumo National General Hospital, Jakarta from January 2018 to December 2019. Ovarian cancer patients undergoing laparotomy surgery were included in the study. Patients with a history of other cancers or having incomplete data were excluded from the study. Intraoperative complications included intestinal, ureter, bladder injury, and postoperative complications included paralytic ileus, surgical wound infection and sepsis were documented.Results: A total of 78 subjects were included in the study. The total proportion of complications was 19.2%. The most prevalent intraoperative complications were intestinal injury (12.8%), bladder injury (2.6%), and ureter injury (1.3%). Most prevalent postoperative complications reported were surgical wound infection (5.2%), sepsis (3.9%), while none of the patients had paralytic ileus.Conclusion: The proportion of intraoperative and postoperative complications in ovarian cancer surgery was still at alarming level (19.2%). Further steps are needed to ameliorate the rate of complications surrounding ovarian cancer surgery.

THE EFFECT OF SUCKING LOLLIPOPS ON RETURN OF BOWEL FUNCTION AFTER ELECTIVE DISTAL BOWEL SURGERY IN CHILDREN.

BACKGROUND-The phenomenon of cessation of coordinated bowel motility, commonly called as paralytic ileus is well known after certain surgeries. While procedures that involve direct manipulation of gut are almost always associated with post operative paralytic ileus, even orthopaedic surgeries may also cause post operative paralytic ileus. It contributes signicantly in prolonging hospital stay and is associated with abdominal distension, respiratory compromise, nausea and vomiting. Number of pharmacological and non pharmacological agents have been tried to reduce the post operative paralytic ileus. We studied the effect of sucking lollipop on the return of bowel function in children undergoing distal bowel surgery. AIM-To study effect of lollipop sucking on return of bowel function in children undergoing distal bowel surgery in terms of time to return of bowel, passage of stool per anal. MATERIALAND METHODS-Patients undergoing distal bowel stoma closure were assigned to two groups. The experimental group patients were given lollipops 6 hrs postoperatively, time to return of bowel sound and rst passage of stool was noted and analysed. RESULTS-Mean time to return of bowel sounds in the experimental group was 50.25 + 6.016 hrs, while in control group was 65.87 + 8.83 hrs, difference was statistically signicant (P<0.0001).Mean time to passage of stools in experimental group was 72.312 +12.644 hrs , while in control group was 88.25 + 8.38 hrs. difference was statistically signicant(P=0.0002) . CONCLUSION- Sucking lollipop is a safe and effective in reducing duration of post operative paralytic ileus in paediatric patients undergoing elective bowel surgery.

Prevalence and Updated Management of Paralytic Ileus: A Simple Review

The study aims to summarize the updated evidence regards, epidemiology, causes, clinical manifestations, and management of paralytic ileus. Lower abdominal surgical procedure, particularly big open cuts and increased bowel operations, is linked with an increased hazard of bowel obstruction. Though, numerous risk issues have been revealed to upsurge the probability and resistance of intestinal obstruction, such as prolonged abdominal / pelvic surgery, lower gastrointestinal (GI) surgery, open surgery, retroperitoneal spine surgery, opioid use, cancer peritoneal, intra-abdominal inflammation (sepsis / peritonitis), delayed enteral nutrition or nasogastric (NG) tube placement, and hypokalemia. Signs of intestinal obstruction are tachycardia caused by any interruption of movement, absence of abdominal pain, abdominal distention and tenderness, shortness of breath, and hypovolemia. Bowel sounds disappear and flatulence is not discharged, leading to gastric stasis, which can cause hiccups, discomfort, and easy vomiting. Preventive measures include avoiding unnecessary exposure and over-processing of the intestine or traction of the mesentery. Treatment is conservative, as this condition is mostly self-limited. Pharmacologic Therapy have little place, but there are some exceptions of adequate values.

TOURNIQUET APPENDIX: RARE ETIOLOGY OF ORGANIC ACUTE INTESTINAL OBSTRUCTION

Acute appendicitis is the most common surgical emergency. A bowel obstruction due to the appendicitis is in most cases functional with a paralytic ileus mechanical bowel obstructions are rare or exceptional. We describe a rare case of a mechanical bowel obstruction due to a strangulation of the last ileal loop by the appendix.