Multidisciplinary intestinal rehabilitation in acute type II intestinal failure: Results from an intestinal rehabilitation team

BackgroundType II (acute) intestinal failure (IF) is usually caused by complications of abdominal surgery resulting in enteric fistulas or proximal stomas and requires parenteral nutrition (PN) for several months. This study aimed to evaluate clinical management and outcome of type II IF patients in a single center.MethodsMedical records of patients referred to the Intestinal Rehabilitation Team (IRT) at Samsung Medical Center (Seoul, Korea) were retrospectively analyzed.ResultsFrom 2014 to 2019, 34 patients with IF were referred. 28 patients were type II IF and were included in the analysis. There were 17 males and 11 females. Mean age of patients was 56.7 years. Pathophysiology of IF were high-output stoma in 16 cases, extensive bowel resection (with bowel in continuity) in 7 cases, and enterocutaneous fistula in 5 cases. The catastrophic events necessitating abdominal surgery in the patients were adhesive ileus in 9 cases, superior mesenteric artery thrombosis in 8 cases, internal herniation of bowel in 5 cases, traumatic bowel injury in 3 cases, and ischemic enteritis in 3 cases. Following medical and surgical rehabilitation, 10 patients (35.7%) were weaned off PN and overall mortality was 28.5%. Deaths were related to progression of underlying malignancies in 4 cases, liver failure in 3 cases, and sepsis in 1 case. Thirteen patients underwent surgery to restore bowel continuity. Six postoperative complications occurred in 4 patients (30.7%) and there were no postoperative mortalities.ConclusionStandardized care including restorative surgery resulted in successful outcomes in type II IF patients in this cohort.     

Is laparoscopic liver resection safe for intrahepatic cholangiocarcinoma? A meta-analysis

BackgroundThe use of laparoscopic liver resection for curative surgery of intrahepatic cholangiocarcinoma (ICC) is not well established. Herein, we perform a meta-analysis to compare the differences between laparoscopic liver resection (LLR) and open liver resection (OLR) for ICC.MethodsMultiple electronic databases were searched and 8 relevant studies containing 552 patients treated by LLR and 2320 treated by OLR were identified. The fixed effects and a random-effects model were used to perform a meta-analysis.ResultsCompared with OLR, LLR for ICC was associated with less blood transfusion (7.14% versus 17.11%; OR: 0.32; 95% CI 0.15 to 0.71; P < 0.05), higher R0 resection (85.63% versus 74.69%; OR: 1.48; 95% CI 1.13 to 1.95; P < 0.05), shorter length of stay (LOS) (SMD: −0.40; 95% CI -0.80 to 0.00; P = 0.05), less overall morbidities (20% versus 32.69%; OR: 0.50; 95% CI 0.33 to 0.78; P < 0.05), and less death due to tumor recurrence (22.39% versus 35.48%; OR: 0.50; 95% CI 0.29 to 0.86; P <0.05); but LLR was associated with smaller ICC, fewer major hepatectomies, less lymph node (LN) dissection rate, and inferior 5-year overall survival (OS) (P < 0.05). Duration of operation, blood loss, average LN retrieved, LN metastasis, major morbidities, mortality, tumor recurrence, 3-year OS and disease free survival (DFS), and 5-year DFS were comparable (P >0.05).ConclusionLLR for ICC is in the initial phase of exploration. More evidence is necessary to validate LLR for ICC.     

Acute liver injury,acute liver failure and acute on chronic liver failure: A clinical spectrum of poisoning due to Gyromitra esculenta

Gyromitra esculenta, also known as “false morel” is one of the most poisonous mushrooms. This species is found all over the world, growing in coniferous forest in early spring time. Common manifestation of poisoning includes gastrointestinal symptoms which include varied degrees of liver impairment.We describe three cases: acute liver injury, acute liver failure and acute-on-chronic liver failure due to G. esculenta poisoning. At admission patients presented with encephalopathy and features of liver failure. Two of them recovered completely following supportive management while the remaining patient who also had preexisting liver disease developed multiorgan failure and subsequently died.Although a rare occurrence, G. esculenta poisoning should be considered in the differential diagnosis of acute liver failure.     

Mechanistic insight,diagnosis, and treatment of ammonia‐induced hepatic encephalopathy

Hepatic encephalopathy is a neuropsychological syndrome due to biochemical disturbance of brain function in advanced liver disease patients. Diagnosis and treatment of the condition is very demanding and has negative toll on finances with increased healthcare utilization. The pathophysiology is not completely understood; however, there is evidence that ammonia plays an important role in the etiology. Conventional methods of solely relying on blood ammonia level to diagnose hepatic encephalopathy did not help much; likewise, the use of lactulose alone in treating hepatic encephalopathy has also been discouraged. This paper analyzed the current knowledge regarding the mechanism of how ammonia disrupts the normal brain function as well as the use of latest diagnosing tools including those under development to evaluate the neuropsychiatric state of patients and their quality of life. The efficacies of lactulose and rifaximin combination for short‐term and long‐term treatment in addition to nutritional interventions and other drugs undergoing clinical trials were also reviewed.