Transcutaneous electrical acupoint stimulation combined with electroacupuncture for rapid recovery of patients after laparotomy for gastrointestinal surgery: a study protocol for a randomised controlled trial

IntroductionAbdominal surgery is associated with common complications, including decreased or poor appetite, abdominal distension, abdominal pain caused by decreased or absent gastrointestinal motility, anal arrest with flatus and defecation, and nausea and vomiting resulting from the use of anaesthetics and opioid analgesics. These complications seriously affect postoperative recovery, prolong hospital stay and aggravate patient burden. This study aims to investigate for the first time the efficacy of transcutaneous electrical acupoint stimulation (TEAS) combined with electroacupuncture (EA) therapy for rapid recovery after laparotomy for gastrointestinal surgery. There have been no clinical studies of this combination therapy.Methods and analysisThis will be a prospective, single-centre, three-arm, randomised controlled trial. A total of 480 patients undergoing abdominal surgery will be stratified according to surgery type (ie, gastric or colorectal procedure) and randomised into three groups; namely, the EA, TEAS +EA and control groups. The control group will receive enhanced recovery after surgery (ERAS)-standardised perioperative management, including preoperative education, optimising the anaesthesia scheme, avoiding intraoperative hypothermia, restrictive fluid infusion and reducing surgical trauma. The EA group will receive EA stimulation at LI4, PC6, ST36, ST37 and ST39 based on the ERAS-standardised perioperative management. Moreover, the TEAS +EA group will receive ERAS-standardised perioperative management; EA stimulation at the LI4, PC6, ST36, ST37 and ST39; and TEAS stimulation at ST21 and SP15. The primary outcome will be the GI-2 (composite outcome of time to first defaecation and time to tolerance of a solid diet). Secondary outcomes will include the time of first passage of flatus, time to first defaecation, time to tolerance of a solid diet, time to first ambulation, hospital duration from operation to discharge, pain and nausea vomiting scores on the Visual Analogue Scale, medication use, incidence of postoperative complications and evaluation of treatment modality acceptability. All statistical analyses will be performed based on the intention-to-treat principle.Ethics and disseminationEthics approval has been granted by the Ethics Committee on Biomedical Research, West China Hospital of Sichuan University (approval number: 2021; number 52). The results are expected to be published in peer-reviewed journals.Trial registration numberChiCTR2100045646.

Expression Levels of Detoxification Enzyme Genes from Dendroctonus armandi (Coleoptera: Curculionidae) Fed on a Solid Diet Containing Pine Phloem and Terpenoids

Bark beetles overcome the toxic terpenoids produced by pine trees by both detoxifying and converting them into a pheromone system. Detoxification enzymes such as cytochrome P450s, glutathione S-transferases, and carboxylesterases are involved in the ability of Dendroctonus armandi to adapt to its chemical environment. Ten genes from these three major classes of detoxification enzymes were selected to study how these enzymes help D. armandi to respond to the host defenses. The expression profile of these detoxification enzyme genes was observed in adult beetles after feeding on different types of diet. Significant differences were observed between two types of seminatural diet containing the phloem of pines, and a purely artificial diet containing five monoterpenes ((−)-α-pinene, (−)-β-pinene, (+)-3-carene, (±)-limonene, and turpentine oil) also caused differential transcript levels in the detoxification enzyme genes. The results suggest that monoterpenes enter the beetles through different routes (i.e., respiratory and digestive systems) and cause the expression of different genes in response, which might be involved in pheromone metabolism. In addition, the xenobiotic metabolism in bark beetles should be considered as a system comprising multiple detoxifying enzymes.

Segmental transverse colectomy. Minimally invasive versus open approach: results from a multicenter collaborative study

The role of minimally invasive surgery in the treatment of transverse colon cancer is still controversial. The aim of this study is to investigate the advantages of a totally laparoscopic technique comparing open versus laparoscopic/robotic approach. Three hundred and eighty-eight patients with transverse colon cancer, treated with a segmental colon resection, were retrospectively analyzed. Demographic data, tumor stage, operative time, intraoperative complications, number of harvested lymph nodes and recovery outcomes were recorded. Recurrences and death were also evaluated during the follow-up. No differences were found between conventional and minimally invasive surgery, both for oncological long-term outcomes (recurrence rate p = 0.28; mortality p = 0.62) and postoperative complications (overall rate p = 0.43; anemia p = 0.78; nausea p = 0.68; infections p = 0.91; bleeding p = 0.62; anastomotic leak p = 0.55; ileus p = 0.75). Nevertheless, recovery outcomes showed statistically significant differences in favor of minimally invasive surgery in terms of time to first flatus (p = 0.001), tolerance to solid diet (p = 0.017), time to first mobilization (p = 0.001) and hospital stay (p = 0.004). Compared with laparoscopic approach, robotic surgery showed significantly better results for time to first flatus (p = 0.001), to first mobilization (p = 0.005) and tolerance to solid diet (p = 0.001). Finally, anastomosis evaluation confirmed the superiority of intracorporeal approach which showed significantly better results for time to first flatus (p = 0.001), to first mobilization (p = 0.003) and tolerance to solid diet (p = 0.001); moreover, we recorded a statistical difference in favor of intracorporeal approach for infection rate (p = 0.04), bleeding (p = 0.001) and anastomotic leak (p = 0.03). Minimally invasive approach is safe and effective as the conventional open surgery, with comparable oncological results but not negligible advantages in terms of recovery outcomes. Moreover, we demonstrated that robotic approach may be considered a valid option and an intracorporeal anastomosis should always be preferred.

1074 Gallstone Ileus: Two Decades After Cholecystectomy

Introduction Gallstone ileus is a rare complication of gallstones that occurs in 1%-4% of all cases of bowel obstruction. We present a surprising case of gallstone ileus causing small bowel obstruction 19 years after open cholecystectomy. Case Report A 77-year-old male presented with a 3-day history of abdominal pain, 4 episodes of vomiting and absolute constipation. He had a surgical background of an open cholecystectomy and open appendicectomy 19 years and 45 years ago respectively. Medically, he had well-controlled hypertension and experienced a TIA 5 years prior. Computed Tomography Scan of the abdomen and pelvis revealed features consistent with an obstructing, heterogenous opacity in the distal small bowel without pneumobilia. The patient subsequently underwent diagnostic laparoscopy. Intraoperatively, an obstructing gallstone, measuring 4 cm, was found 50cm proximal to the ileocaecal junction, with dilatation of the proximal small bowel and distal collapse. Enterotomy and removal of the stone was done. Post-operatively, this gentleman recovered without complications and was discharged home two days later after being able to tolerate a solid diet. Conclusions This is the second reported case of gallstone ileus in a patient with previous cholecystectomy about two decades ago, according to our literature search. Although extremely rare, absence of the gallbladder does not exclude the possibility of gallstone ileus.

821 Comparative Effectiveness of Interventions to Reduce Ileus After Colorectal Surgery: A Network Meta-Analysis

Aim Several treatment strategies for post-operative ileus have been evaluated in randomised controlled trials. This network meta-analysis aimed to explore the relative effectiveness of these different therapies on their impact on ileus outcome measures. Method A systematic review was conducted to identify randomised controlled trials reported up to 23rd April 2020. Indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis. Results A total of 48 randomised controlled trials, reporting any combination of five different outcome measures of time to flatus, stool, and solid diet tolerance, or nasogastric tube post-operative insertion, or length of stay following colorectal surgery were identified. In this network meta-analysis, early feeding was ranked first for time to solid diet tolerance (Mean Difference (hours) -58.845 CrI (-73.414, -43.150; rank 1 p = 0.960) and length of hospital stay (Mean Difference (hours) -2.326; CrI -3.510, -1.184; rank 1 p = 0.465) with high probability of first rank in the remainder of measures. Epidural analgesia was ranked first for time to flatus (Mean Difference (hours) -18.882; CrI -33.673, -3.435; rank 1 p = 0.286) and time to stool (Mean Difference (hours) -26.054; 95% CrI -66.417, 15.645; rank 1 p = 0.268). Conclusions This network meta-analysis identified early feeding as the most efficacious therapeutic to reduce post-operative ileus in patients undergoing colorectal surgery. High quality studies of the efficacious therapeutics to reduce ileus following colorectal surgery highlighted in this review are required with established core outcome measures of gastrointestinal mobility.

Temporal and nutritional effects on the weaner pig ileal microbiota

Background The porcine gastrointestinal microbiota has been linked to both host health and performance. Most pig gut microbiota studies target faecal material, which is not representative of microbiota dynamics in other discrete gut sections. The weaning transition period in pigs is a key development stage, with gastrointestinal problems being prominent after often sudden introduction to a solid diet. A better understanding of both temporal and nutritional effects on the small intestinal microbiota is required. Here, the development of the porcine ileal microbiota under differing levels of dietary protein was observed over the immediate post-weaning period. Results Ileal digesta samples were obtained at post-mortem prior to weaning day (day − 1) for baseline measurements. The remaining pigs were introduced to either an 18% (low) or 23% (high) protein diet on weaning day (day 0) and further ileal digesta sampling was carried out at days 5, 9 and 13 post-weaning. We identified significant changes in microbiome structure (P = 0.01), a reduction in microbiome richness (P = 0.02) and changes in the abundance of specific bacterial taxa from baseline until 13 days post-weaning. The ileal microbiota became less stable after the introduction to a solid diet at weaning (P = 0.036), was highly variable between pigs and no relationship was observed between average daily weight gain and microbiota composition. The ileal microbiota was less stable in pigs fed the high protein diet (P = 0.05), with several pathogenic bacterial genera being significantly higher in abundance in this group. Samples from the low protein and high protein groups did not cluster separately by their CAZyme (carbohydrate-active enzyme) composition, but GH33 exosialidases were found to be significantly more abundant in the HP group (P = 0.006). Conclusions The weaner pig ileal microbiota changed rapidly and was initially destabilised by the sudden introduction to feed. Nutritional composition influenced ileal microbiota development, with the high protein diet being associated with an increased abundance of significant porcine pathogens and the upregulation of GH33 exosialidases—which can influence host-microbe interactions and pathogenicity. These findings contribute to our understanding of a lesser studied gut compartment that is not only a key site of digestion, but also a target for the development of nutritional interventions to improve gut health and host growth performance during the critical weaning transition period.

Nutrition and Antibiotics for Acute Pancreatitis

Acute pancreatitis is a sudden inflammatory disease that could be developed into a fatal condition. Traditional dogma was to rest the pancreas by fasting. However, evidence shows the benefits of early enteral feeding resulting in a shorter hospital stay, improved mortality, multi-organ failure, systemic infections, and the need for operative interventions. Clinicians should encourage enteral feeding as soon as possible even in severe acute pancreatitis if there are no contraindications. An immediate solid diet could be attempted. Regarding tube feeding, the nasojejunal tube did not show superiority to the nasogastric tube. Different formulas and probiotics need more investigation. Guidelines are against using prophylactic antibiotics, but Korean centers still report overuse of antibiotics. However, there is still a debate about using prophylactic antibiotics in severe acute pancreatitis. Broad-spectrum antibiotics should be initiated when an infection is suspected. In conclusion, enteral nutritional support and optimal use of antibiotics are the keys to the management of acute pancreatitis.

Transcriptomic analysis reveals the molecular mechanisms of rumen wall morphological and functional development induced by different solid diet introduction in a lamb model

Background This study aimed to elucidate the molecular mechanisms of solid diet introduction initiating the cellular growth and maturation of rumen tissues and characterize the shared and unique biological processes upon different solid diet regimes. Methods Twenty-four Hu lambs were randomly allocated to three groups fed following diets: goat milk powder only (M, n = 8), goat milk powder + alfalfa hay (MH, n = 8), and goat milk powder + concentrate starter (MC, n = 8). At 42 days of age, the lambs were slaughtered. Ruminal fluid sample was collected for analysis of concentration of volatile fatty acid (VFA) and microbial crude protein (MCP). The sample of the rumen wall from the ventral sac was collected for analysis of rumen papilla morphology and transcriptomics. Results Compared with the M group, MH and MC group had a higher concentration of VFA, MCP, rumen weight, and rumen papilla area. The transcriptomic results of rumen wall showed that there were 312 shared differentially expressed genes (DEGs) between in “MH vs. M” and “MC vs. M”, and 232 or 796 unique DEGs observed in “MH vs. M” or “MC vs. M”, respectively. The shared DEGs were most enriched in VFA absorption and metabolism, such as peroxisome proliferator-activated receptor (PPAR) signaling pathway, butanoate metabolism, and synthesis and degradation of ketone bodies. Additionally, a weighted gene co-expression network analysis identified M16 (2,052 genes) and M18 (579 genes) modules were positively correlated with VFA and rumen wall morphology. The M16 module was mainly related to metabolism pathway, while the M18 module was mainly associated with signaling transport. Moreover, hay specifically depressed expression of genes involved in cytokine production, immune response, and immunocyte activation, and concentrate starter mainly altered nutrient transport and metabolism, especially ion transport, amino acid, and fatty acid metabolism. Conclusions The energy production during VFA metabolism may drive the rumen wall development directly. The hay introduction facilitated establishment of immune function, while the concentrate starter enhanced nutrient transport and metabolism, which are important biological processes required for rumen development.

Lysine and Methionine Supplementation for Dairy Calves Is More Accurate through the Liquid than the Solid Diet

This study aimed to evaluate the performance and metabolic changes in dairy calves supplemented with lysine and methionine in milk replacer (MR) or starter concentrate (SC). Male Holstein calves (n = 45) were blocked and distributed in Control without supplementation (1) and; Lysine and Methionine supplementation to achieve an intake of 17 and 5.3 g/d in the SC (2) and to achieve of 17 and 5.3 g/d in the MR (3). MR was fed (6 L/d) until the 8th week of life when weaning occurred. Calves were followed until the 10th week of age. Feed intake was measured daily. Weight and body measurements were registered weekly. Blood samples were collected biweekly to evaluate the intermediate metabolism. The AA supplementation resulted in lower body weight at weaning and week 10. Calves fed SC Lys:Met had lower SC intake and lower total feed intake at weaning when compared to control. Calves fed control had higher heart girth, hip-width, and plasma glucose concentration. The supplementation with Lys and Met did not benefit dairy calves’ performance nor metabolism in this study. Supplementation through the MR was more efficient than SC to result in adequate daily intakes of AA. Further studies are needed to understand the negative effects of AA on calf starter intake.