Abdominal adhesiolysis: inpatient care and expenditures in the United States in 1994

A novel coenzyme-Q approach for the prevention of postsurgical adhesion

Objectives

Postoperative intraperitoneal adhesions are an unsolved and important problem in abdominal surgery. In the present study, the probable preventive role of coenzyme-Q in the development of peritoneal adhesions was investigated.

Material and Methods

Sixteen Wistar Hannover male rats weighing 300-350 g were randomly separated into two groups of 8 rats each. The cecum was abraded with a sterile gauze until sub-serosal hemorrhage developed. A patch of peritoneum located opposite to the cecal abrasion was completely dissected. No treatment was given to Group 1. Group 2 received 30 mg/kg coenzyme-Q, which was injected 2 mL intraperitoneally. All the rats were sacrificed on the postoperative 21^st day, and after adhesions were scored macroscopically, tissue specimens of the peritoneum and bowel were subjected to histopathological investigation. Tissue and blood specimens were also taken for biochemical analysis to investigate antioxidant efficiency.

Results

Adhesion scores were significantly different between the control group and the coenzyme-Q group (p= 0.001). According to the tissue levels of GSH-Px, MDA, and SOD levels, there was no significant difference between the study groups (p= 0.074, p= 0.208, p= 0.526). According to the plasma GSH-Px and SOD levels, there was significant difference between the groups (p= 0.002, p= 0.001), but the difference was not significant at MDA levels (p= 0.793). The differences between the pathological scores of the control and coenzyme-Q (p= 0.028 for fibrosis; p= 0.025 for inflammation) groups were statistically significant.

Conclusion

This study confirms that coenzyme-Q is the potential application in the prevention of early postoperative adhesions.

Peritoneal adhesions during cesarean delivery are an independent risk factor for peri-partum hemorrhagic complications

OBJECTIVE

To investigate whether the presence of peritoneal adhesions at the second cesarean delivery (CD) are associated with peri-partum hemorrhagic complications.

STUDY DESIGN

A retrospective cohort study was undertaken, comparing hemorrhagic complications in the second CD, between women with and without adhesions. All women with two CDs who delivered a singleton in their second CD between the years 1988-2016 at a large regional medical center in Israel were included. Women with adhesions diagnosed at the first CD and women with a history of other abdominal or pelvic surgery, pelvic infection or inflammatory disease, endometriosis, uterine Mullerian anomalies and fetal chromosomal or structural abnormalities were excluded from the analysis, resulting in a sample of 7925 women. Peri-partum hemorrhagic complications were defined as a composite of vessel ligation, B lynch procedure during the CD or uterine rupture, third stage or immediate postpartum hemorrhage, blood component transfusion, hemorrhagic shock and maternal anemia [hemoglobin (Hb) levels prior to maternal discharge below 9.0 g\dl]. In order to identify variables that are independently associated with the composite peri-partum hemorrhagic complications a multivariate logistic regression analysis was performed, to control for potential confounders. In addition, a linear regression model was constructed with Hb levels as the outcome variable.

RESULTS

During the study period, 32.6 % of patients (n = 2581) suffered from adhesions during the second CD. After adjusting for potential confounders, peri-partum hemorrhagic complications were found to be significantly associated with the presence of peritoneal adhesions (adjusted OR 1.18, CI 1.04-1.33, P = 0.008). A multivariate linear regression analysis revealed that peritoneal adhesions were independently associated with a decline in post-partum Hb levels (β=-0.055, P < 0.001).

CONCLUSION

Adhesions attributable to a previous CD increase the risk for hemorrhagic complications. Interventions aimed at preventing adhesions formation during the primary CD may have a role in reducing hemorrhagic complications in subsequent CDs.

A Novel Rat Model to Test Intra-Abdominal Anti-adhesive Therapy

Background: Adhesion formation after abdominal surgery is considered almost inevitable and a major cause of morbidity. Novel treatments have been proposed, however there is a lack of suitable small animal models for pre-clinical evaluation, mainly due to inconsistency in adhesion formation in positive control animals. Here, we propose a new rat model of abdominal adhesions using Kaolin as the adhesion-inducing agent at an optimized dosage for testing newer agents in respect to their anti-adhesive property.

Materials and Methods: Twenty-five adult (8–10 week old) male Wistar albino rats underwent midline laparotomy and caecal abrasion and were randomized to receive topical applications of normal saline or different concentrations and volumes of a Kaolin-based formulation. At day 14 rats were humanely killed, and adhesions graded macroscopically by an investigator blinded to the treatment groups, using pre-determined adhesion scores and microscopically using histopathology.

Results: Kaolin at 0.005 g/mL caused consistent adhesions without compromising rat viability. At higher doses significant morbidity and mortality was observed in the animals treated.

Conclusions: Kaolin induced adhesion in a rat abdominal surgery model is reliable and can be safely used to test the efficacy of novel anti-adhesive formulations to prevent intra-abdominal adhesions.

Mechanisms of adhesive small bowel obstruction and outcome of surgery; a population-based study

BACKGROUND

This study aims to describe the mechanisms of adhesive small bowel obstruction (SBO) and its morbidity, mortality and recurrence after surgery for SBO in a defined population.

METHOD

Retrospective study of 402 patients (240 women, median age 70 years, range 18-97) who underwent surgery for SBO in the Uppsala and Gävleborg regions in 2007-2012. Patients were followed to last note in medical records or death.

RESULT

The cause of obstruction was a fibrous band in 56% and diffuse adhesions in 44%. Early overall postoperative morbidity was 48 and 10% required a re-operation. Complications, intensive care and early mortality (n = 21, 5.2%) were related to age (p < 0.05) and American Society of Anesthesiologist's class (p < 0.01). At a median follow-up of 66 months (0-122), 72 patients (18%) had been re-admitted because of SBO; 26 of them underwent a re-operation. Previous laparotomies (p = 0.013), diffuse adhesions (p = 0.050), and difficult surgery (bowel injury, operation time and bleeding, p = 0.034-0.003) related to recurrent SBO. The cohort spent 6735 days in hospital due to SBO; 772 of these days were due to recurrent SBO. In all, 61% of the cohort was alive at last follow-up. Late mortality was related to malignancies, cardiovascular disease, and other chronic diseases.

CONCLUSIONS

About half of patients with SBO are elderly with co-morbidities which predispose to postoperative complications and mortality. Diffuse adhesions, which make surgery difficult, were common and related to future SBO. Overall, nearly one-fifth of patients needed re-admission for recurrent SBO. Continued research for preventing SBO is desirable.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT03534596, retrospectively registered, 2018-05-24).

Establishing core outcome sets for gastrointestinal recovery in studies of postoperative ileus and small bowel obstruction: protocol for a nested methodological study

INTRODUCTION

Gastrointestinal recovery describes the restoration of normal bowel function in patients with bowel disease. This may be prolonged in two common clinical settings: postoperative ileus and small bowel obstruction. Improving gastrointestinal recovery is a research priority but researchers are limited by variation in outcome reporting across clinical studies. This protocol describes the development of core outcome sets for gastrointestinal recovery in the contexts of postoperative ileus and small bowel obstruction.

METHOD

An international Steering Group consisting of patient and clinician representatives has been established. As overlap between clinical contexts is anticipated, both outcome sets will be co-developed and may be combined to form a common output with disease-specific domains. The development process will comprise three phases, including definition of outcomes relevant to postoperative ileus and small bowel obstruction from systematic literature reviews and nominal-group stakeholder discussions; online-facilitated Delphi surveys via international networks; and a consensus meeting to ratify the final output. A nested study will explore if the development of overlapping outcome sets can be rationalized.

DISSEMINATION AND IMPLEMENTATION

The final output will be registered with the Core Outcome Measures in Effectiveness Trials initiative. A multi-faceted, quality improvement campaign for the reporting of gastrointestinal recovery in clinical studies will be launched, targeting international professional and patient groups, charitable organizations and editorial committees. Success will be explored via an updated systematic review of outcomes 5 years after registration of the core outcome set.

Longer Trials of Non-operative Management for Adhesive Small Bowel Obstruction Are Associated with Increased Complications

BACKGROUND

Current guidelines for the management of adhesive small bowel obstruction suggest a limited trial of non-operative management, often of 3-5 days. A longer delay to operation may worsen post-operative outcomes in patients who ultimately require operation. Our objective was to evaluate the impact of time to operation on post-operative outcomes in patients who undergo operation following a trial of non-operative management for adhesive small bowel obstruction.

METHODS

We used health administrative data to identify patients with adhesive small bowel obstruction who underwent operative management following a trial of non-operative management from 2005 to 2014 in the province of Ontario, Canada. We used multivariable logistic regression to examine the relationship between the time from admission to operation with rates of 30-day mortality, serious complication, and bowel resection.

RESULTS

Three thousand five hundred sixty-three patients underwent operation after a trial of non-operative management for adhesive small bowel obstruction. Older patients, patients with a high comorbidity burden, and patients with a lower socioeconomic status were more likely to experience a longer pre-operative period. After adjusting for covariates, each additional day from admission to operation increased odds of serious complication (OR = 1.07, 95% CI = 1.03-1.11) and bowel resection (OR = 1.06, 95% CI = 1.03-1.98). Longer times to operation were not associated with greater adjusted odds of 30-day mortality.

CONCLUSION

Each additional day from admission to operation is associated with greater odds of adverse outcomes. Clinical practice guidelines should emphasize strategies that identify patients who will ultimately require operation.

Association of Surgical Intervention for Adhesive Small-Bowel Obstruction With the Risk of Recurrence

Importance

Adhesive small-bowel obstruction (aSBO) is a potentially chronic, recurring surgical illness. Although guidelines suggest trials of nonoperative management, the long-term association of this approach with recurrence is poorly understood.

Objective

To compare the incidence of recurrence of aSBO in patients undergoing operative management at their first admission compared with nonoperative management.

Design, Setting, and Participants

This longitudinal, propensity-matched, retrospective cohort study used health administrative data for the province of Ontario, Canada, for patients treated from April 1, 2005, through March 31, 2014. The study population included adults aged 18 to 80 years who were admitted for their first episode of aSBO. Patients with nonadhesive causes of SBO were excluded. A total of 27 904 patients were included and matched 1:1 by their propensity to undergo surgery. Factors used to calculate propensity included patient age, sex, comorbidity burden, socioeconomic status, and rurality of home residence. Data were analyzed from September 10, 2017, through October 4, 2018.

Exposures

Operative vs nonoperative management for aSBO.

Main Outcomes and Measures

The primary outcome was the rate of recurrence of aSBO among those with operative vs nonoperative management. Time-to-event analyses were used to estimate hazard ratios of recurrence while accounting for the competing risk of death.

Results

Of 27 904 patients admitted with their first episode of aSBO, 6186 (22.2%) underwent operative management. Mean (SD) patient age was 61.2 (13.6) years, and 51.1% (14 228 of 27 904) were female. Patients undergoing operative management were younger (mean [SD] age, 60.2 [14.3] vs 61.5 [13.4] years) with fewer comorbidities (low burden, 382 [6.2%] vs 912 [4.2%]). After matching, those with operative management had a lower risk of recurrence (13.0% vs 21.3%; hazard ratio, 0.62; 95% CI, 0.56-0.68; P < .001). The 5-year probability of experiencing another recurrence increased with each episode until surgical intervention, at which point the risk of subsequent recurrence decreased by approximately 50%.

Conclusions and Relevance

According to this study, operative management of the first episode of aSBO is associated with significantly reduced risk of recurrence. Guidelines advocating trials of nonoperative management for aSBO may assume that surgery increases the risk of recurrence putatively through the formation of additional adhesions. The long-term risk of recurrence of aSBO should be considered in the management of this patient population.

Outcomes of a low-osmolar water-soluble contrast pathway in small bowel obstruction

BACKGROUND

Adhesive small-bowel obstruction (SBO) is a common surgical condition accounting for a significant proportion of acute surgical admissions and surgeries. The implementation of a high-osmolar water-soluble contrast challenge has repeatedly been shown to reduce hospital length of stay and possibly the need for surgery in SBO patients. The effect of low-osmolar water-soluble contrast challenge however, is unclear. The aim of this study is to evaluate the outcomes of an SBO pathway including a low-osmolar water-soluble contrast challenge.

METHODS

A prospective cohort of patients admitted for SBO were placed on an evidence-based SBO pathway including low-osmolar water-soluble contrast between January 2017 and October 2018 and were compared with a historical cohort of patients prior to the implementation of the pathway from September 2013 through December 2014. The primary outcome was length of stay less than 4 days with a secondary outcome of failure of nonoperative management.

RESULTS

There were 140 patients enrolled in the SBO pathway during the study period and 101 historic controls. The SBO pathway was independently associated with a length of stay less than 4 days (odds ratio, 1.76; 95% confidence interval, 1.03-3.00). Median length of stay for patients that were successfully managed nonoperatively was lower in the SBO pathway cohort compared with controls (3 days vs. 4 days, p = 0.04). Rates of readmission, surgery, and bowel resection were not significantly different between the two cohorts.

CONCLUSION

Implementation of an SBO pathway using a low-osmolarity contrast is associated with decreased hospital length of stay. Rates of readmission, surgery, and need for bowel resection for those undergoing surgery were unchanged. An SBO pathway utilizing low-osmolarity water-soluble contrast is safe and effective in reducing length of stay in the nonoperative management of adhesive small-bowel obstructions.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Identification of candidate biomarkers correlated with pathogenesis of postoperative peritoneal adhesion by using microarray analysis

BACKGROUND

Postoperative peritoneal adhesion (PPA), characterized by abdominal pain, female infertility, and even bowel obstruction after surgery, has always been a major concern. The occurrence and formation of adhesion are from complex biological processes. However, the molecular mechanisms underlying the basis of microarray data profile, followed by peritoneal adhesion formation, are largely unknown.

AIM

To reveal the underlying pathogenesis of PPA at the molecular level.

METHODS

The gene expression profile was retrieved from the Gene Expression Omnibus database for our analysis. We identified a panel of key genes and related pathways involved in adhesion formation using bioinformatics analysis methods. We performed quantitative PCR and western blotting in vivo to validate the results preliminarily.

RESULTS

In total, 446 expressed genes were altered in peritoneal adhesion. We found that several hub genes (e.g., tumor necrosis factor, interleukin 1 beta, interleukin 6, C-X-C motif chemokine ligand 1, C-X-C motif chemokine ligand 2) were marked as significant biomarkers. Functional analysis suggested that these genes were enriched in the Toll-like receptor signaling pathway. According to the Kyoto Encyclopedia of Genes and Genomes pathway and published studies, TLR4, myeloid differentiation primary response protein 88 (MyD88), and nuclear factor kappa B (NF-κB) played essential roles in Toll-like signaling transduction. Here, we obtained a regulatory evidence chain of TLR4/MyD88/NF-κB/inflammatory cytokines/peritoneal adhesion involved in the pathogenesis of postoperative adhesion. The results of the microarray analysis were verified by the animal experiments. These findings may extend our understanding of the molecular mechanisms of PPA.

CONCLUSION

The regulatory evidence chain of TLR4/MyD88/NF-κB/inflammatory cytokines/peritoneal adhesion may play key roles in the pathogenesis of PPA. Future studies are required to validate our findings.

Adhesion reformation and the limited translational value of experiments with adhesion barriers: A systematic review and meta-analysis of animal models

Today, 40-66% of elective procedures in general surgery are reoperations. During reoperations, the need for adhesiolysis results in increased operative time and a more complicated convalescence. In pre-clinical evaluation, adhesion barriers are tested for their efficacy in preventing 'de novo' adhesion formation, However, it is unknown to which extent barriers are tested for prevention of adhesion reformation. The aim of this systematic review and meta-analysis is to assess the efficacy of commercially available adhesion barriers and laparoscopic adhesiolysis in preventing adhesion reformation in animal models. Pubmed and EMBASE were searched for studies which assessed peritoneal adhesion reformation after a standardized peritoneal injury (in the absence of an intra-peritoneal mesh), and reported the incidence of adhesions, or an adhesion score as outcome. Ninety-three studies were included. No study met the criteria for low risk of bias. None of the commercially available adhesion barriers significantly reduced the incidence of adhesion reformation. Three commercially available adhesion barriers reduced the adhesion score of reformed adhesions, namely Seprafilm (SMD 1.38[95% CI]; p < 0.01), PEG (SMD 2.08[95% CI]; p < 0.01) and Icodextrin (SMD 1.85[95% CI]; p < 0.01). There was no difference between laparoscopic or open adhesiolysis with regard to the incidence of adhesion reformation (RR 1.14[95% CI]; p ≥ 0.05) or the adhesion score (SMD 0.92[95% CI]; p ≥ 0.05). Neither currently commercially available adhesion barriers, nor laparoscopic adhesiolysis without using an adhesion barrier, reduces the incidence of adhesion reformation in animal models. The methodological quality of animal studies is poor.

No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain

OBJECTIVE

To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain.

BURDEN OF SUFFERING

CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates.

OUTCOMES

Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state.

EVIDENCE

Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations.

VALUES

The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1).

RECOMMENDATIONS

The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; G) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

HuoXueTongFu Formula Alleviates Intraperitoneal Adhesion by Regulating Macrophage Polarization and the SOCS/JAK2/STAT/PPAR-γ Signalling Pathway

Intraperitoneal adhesion is a common complication after abdominal surgery, which seriously affects the quality of life of patients. HuoXueTongFu Formula (HXTF) plays an important role in the prevention and treatment of intraperitoneal adhesions. However, the molecular-related mechanisms are still not fully known. In this study, the model of Intrapetitoneal adhesion was established by cecum abrasion and treated with HXTF for one week. RAW264.7 cells were given LPS, IFN-γ, IL-4, HXTF-medicated serum, and PPAR-γ agonist/antagonist, respectively. Histopathology, flow cytometry, ELISA, real-time PCR, and Western blotting were used to further detect the related protein, M1/M2 polarization tendency, and PPAR-γ nuclear translocation. The deposition of collagen fibres reduced in the local area of rats after the operation with HXTF treatment. Similar to IL-4, HXTF induced a tendency for macrophages to polarize toward M2 and promoted peroxisome proliferator-activated receptor-gamma (PPAR-γ) nuclear translocation. Furthermore, the use of HXTF and PPAR-γ agonists downregulated macrophage M1 polarization-related factors IL-1, IL-6, and TNF-alpha and upregulated M2 polarization-related factors IL-4, IL-10, and TGF-beta 1. Meanwhile, the use of HXTF and PPAR-γ agonists downregulated the SOCS3/JAK2/STAT1 pathway and activated the SOCS1/STAT6/PPAR-γ pathway. These results show that HXTF may reduce intraperitoneal adhesion by inducing macrophage M2 polarization and regulating the SOCS/JAK2/STAT/PPAR-γ pathway.

Deconstructing dogma: Nonoperative management of small bowel obstruction in the virgin abdomen

BACKGROUND

Management of small bowel obstruction (SBO) has become more conservative, especially in those patients with previous abdominal surgery (PAS). However, surgical dogma continues to recommend operative exploration for SBO with no PAS. With the increased use of computed tomography imaging resulting in more SBO diagnoses, it is important to reevaluate the role of mandatory operative exploration. Gastrografin (GG) administration decreases the need for operative exploration and may be an option for SBO without PAS. We hypothesized that the use of GG for SBO without PAS will be equally effective in reducing the operative exploration rate compared with that for SBO with PAS.

METHODS

A post hoc analysis of prospectively collected data was conducted for patients with SBO from February 2015 through December 2016. Patients younger than 18 years, pregnant patients, and patients with evidence of hypotension, bowel strangulation, peritonitis, closed loop obstruction or pneumatosis intestinalis were excluded. The primary outcome was operative exploration rate for SBO with or without PAS. Rate adjustment was accomplished through multivariate logistic regression.

RESULTS

Overall, 601 patients with SBO were included in the study, 500 with PAS and 101 patients without PAS. The two groups were similar except for age, sex, prior abdominal surgery including colon surgery, prior SBO admission, and history of cancer. Multivariate analysis showed that PAS (odds ratio [OR], 0.47; p = 0.03) and the use of GG (OR, 0.11; p < 0.01) were independent predictors of successful nonoperative management, whereas intensive care unit admission (OR, 16.0; p < 0.01) was associated with a higher likelihood of need for operation. The use of GG significantly decreased the need for operation in patients with and without PAS.

CONCLUSIONS

Patients with and without PAS who received GG had lower rates of operative exploration for SBO compared with those who did not receive GG. Patients with a diagnosis of SBO without PAS should be considered for the nonoperative management approach using GG.

LEVEL OF EVIDENCE

Therapeutic, level IV.

The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review

BACKGROUND

Surgical training has long been to "never let the sun set on a bowel obstruction" without an operation to rule out and/or treat compromised bowel. However, advances in diagnostics have called into question the appropriate timing of non-emergent operations and expectant management is increasingly used. We performed a systematic review to evaluate the safety and effectiveness of expectant management for adhesive small bowel obstruction (aSBO) compared to early, non-emergent operation.

MATERIALS & METHODS

We queried PubMed, EMBASE, and Cochrane databases for studies (1990-present) comparing early, non-emergent operations and expectant management for aSBO (PROSPERO #CRD42017057676).

RESULTS

Of 4873 studies, 29 cohort studies were included for full-text review. Four studies directly compared early surgery with expectant management, but none excluded patients who underwent emergent operations from those having early non-emergent surgery, precluding a direct comparison of the two treatment types of interest. When aggregated, the rate of bowel resection was 29% in patients undergoing early operation vs. 10% in those undergoing expectant management. The rate of successful, non-operative management in the expectant group was 58%. There was a 1.3-day difference in LOS favoring expectant management (LOS 9.7 vs. 8.4 days), and the rate of death was 2% in both groups.

CONCLUSION

Despite the shift towards expectant management of aSBO, no published studies have yet compared early, non-emergent operation and expectant management. A major limitation in evaluating the outcomes of these approaches using existing studies is confounding by indication related to including patients with emergent indications for surgery on admission in the early operative group. A future study, randomizing patients to early non-emergent surgery or expectant management, should inform the comparative safety and value of these approaches.

National prospective cohort study of the burden of acute small bowel obstruction

Background

Small bowel obstruction is a common surgical emergency, and is associated with high levels of morbidity and mortality across the world. The literature provides little information on the conservatively managed group. The aim of this study was to describe the burden of small bowel obstruction in the UK.

Methods

This prospective cohort study was conducted in 131 acute hospitals in the UK between January and April 2017, delivered by trainee research collaboratives. Adult patients with a diagnosis of mechanical small bowel obstruction were included. The primary outcome was in‐hospital mortality. Secondary outcomes included complications, unplanned intensive care admission and readmission within 30 days of discharge. Practice measures, including use of radiological investigations, water soluble contrast, operative and nutritional interventions, were collected.

Results

Of 2341 patients identified, 693 (29·6 per cent) underwent immediate surgery (within 24 h of admission), 500 (21·4 per cent) had delayed surgery after initial conservative management, and 1148 (49·0 per cent) were managed non‐operatively. The mortality rate was 6·6 per cent (6·4 per cent for non‐operative management, 6·8 per cent for immediate surgery, 6·8 per cent for delayed surgery; P = 0·911). The major complication rate was 14·4 per cent overall, affecting 19·0 per cent in the immediate surgery, 23·6 per cent in the delayed surgery and 7·7 per cent in the non‐operative management groups (P < 0·001). Cox regression found hernia or malignant aetiology and malnutrition to be associated with higher rates of death. Malignant aetiology, operative intervention, acute kidney injury and malnutrition were associated with increased risk of major complication.

Conclusion

Small bowel obstruction represents a significant healthcare burden. Patient‐level factors such as timing of surgery, acute kidney injury and nutritional status are factors that might be modified to improve outcomes.

Evaluation of a water-soluble contrast protocol for nonoperative management of pediatric adhesive small bowel obstruction

BACKGROUND/PURPOSE

We examined outcomes before and after implementing an enteral water-soluble contrast protocol for management of pediatric adhesive small bowel obstruction (ASBO).

METHODS

Medical records were reviewed retrospectively for all children admitted with ASBO between November 2010 and June 2017. Those admitted between November 2010 and October 2013 received nasogastric decompression with decision for surgery determined by surgeon judgment (preprotocol). Patients admitted after October 2013 (postprotocol) received water-soluble contrast early after admission, were monitored with serial examinations and radiographs, and underwent surgery if contrast was not visualized in the cecum by 24 h. Group outcomes were compared.

RESULTS

Twenty-six patients experienced 29 admissions preprotocol, and 11 patients experienced 12 admissions postprotocol. Thirteen (45%) patients admitted preprotocol underwent surgery, versus 2 (17%) postprotocol patients (p = 0.04). Contrast study diagnostic sensitivity as a predictor for ASBO resolution was 100%, with 90% specificity. Median overall hospital LOS trended shorter in the postprotocol group, though was not statistically significant (6.2 days (preprotocol) vs 3.6 days (postprotocol) p = 0.12). Pre- vs. postprotocol net operating cost per admission yielded a savings of $8885.42.

CONCLUSIONS

Administration of water-soluble contrast after hospitalization for pediatric ASBO may play a dual diagnostic and therapeutic role in management with decreases in surgical intervention, LOS, and cost.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Emergency Medicine Evaluation and Management of Small Bowel Obstruction: Evidence-Based Recommendations

BACKGROUND

Small bowel obstruction (SBO) is a commonly diagnosed disease in the emergency department (ED). Recent literature has evaluated the ED investigation and management of SBO.

OBJECTIVE

This review evaluates the ED investigation and management of adult SBO based on the current literature.

DISCUSSION

SBO is most commonly due to occlusion of the small intestine, resulting in fluid and gas accumulation. This may progress to mucosal ischemia, necrosis, and perforation. A variety of etiologies are present, but in adults, adhesions are the most common cause. Several classification systems are present. However, the most important distinction is complete vs. partial and complicated vs. simple obstruction, as complete complicated SBO more commonly requires surgical intervention. History and physical examination can vary, but the most reliable findings include prior abdominal surgery, history of constipation, abdominal distension, and abnormal bowel sounds. Signs of strangulation include fever, hypotension, diffuse abdominal pain, peritonitis, and several others. Diagnosis typically requires imaging, and though plain radiographs are often ordered, they cannot exclude the diagnosis. Computed tomography and ultrasound are reliable diagnostic methods. Management includes intravenous fluid resuscitation, analgesia, and determining need for operative vs. nonoperative therapy. Nasogastric tube is useful for patients with significant distension and vomiting by removing contents proximal to the site of obstruction. Surgery is needed for strangulation and those that fail nonoperative therapy. Surgical service evaluation and admission are recommended.

CONCLUSION

SBO is a common reason for admission from the ED. Knowledge of recent literature can optimize diagnosis and management.

Evolving Management Strategies in Patients with Adhesive Small Bowel Obstruction: a Population-Based Analysis

BACKGROUND

In patients with adhesive small bowel obstruction (aSBO), the decision to operate as well as the timing and technique of surgery have significant impacts on clinical outcomes. Trends in the management of aSBO have not been described at the population level and guideline adherence is unknown. We sought to evaluate the secular trends in the management of aSBO in a large North American population.

METHODS

We used administrative data to identify patients admitted to hospital for their first episode of aSBO over 2005-2014. We evaluated temporal trends in admission for aSBO and in management practices using Cochran-Armitage tests. Multivariable logistic regressions were used to assess trends when controlling for potential confounders.

RESULTS

Patients (40,800) were admitted with their first episode of aSBO. The mean age was 68.5 years and 55% of patients were female. The population-based rate of admission for aSBO decreased over the study period, from 39.1 to 38.1 per 100,000 persons per year. There was a significant increase in the proportion of patients who underwent surgery for aSBO (19 to 23%, p < 0.0001). Among those who underwent surgery, there were significant increases in the proportions of patients who underwent laparoscopic procedures (4 to 14%, p < 0.0001) and who underwent surgery within 1 day of admission (51 to 60%, p < 0.0001).

CONCLUSION

Between 2005 and 2014, there was a decrease in the population-based rate of aSBO, which may reflect increased utilization of minimally invasive techniques. There were significant trends towards increased operative intervention, with surgery occurring earlier and increasingly using laparoscopic approach.

Surgical adhesions in mice are derived from mesothelial cells and can be targeted by antibodies against mesothelial markers

Peritoneal adhesions are fibrous tissues that tether organs to one another or to the peritoneal wall and are a major cause of postsurgical and infectious morbidity. The primary molecular chain of events leading to the initiation of adhesions has been elusive, chiefly due to the lack of an identifiable cell of origin. Using clonal analysis and lineage tracing, we have identified injured surface mesothelium expressing podoplanin (PDPN) and mesothelin (MSLN) as a primary instigator of peritoneal adhesions after surgery in mice. We demonstrate that an anti-MSLN antibody diminished adhesion formation in a mouse model where adhesions were induced by surgical ligation to form ischemic buttons and subsequent surgical abrasion of the peritoneum. RNA sequencing and bioinformatics analyses of mouse mesothelial cells from injured mesothelium revealed aspects of the pathological mechanism of adhesion development and yielded several potential regulators of this process. Specifically, we show that PDPN+MSLN+ mesothelium responded to hypoxia by early up-regulation of hypoxia-inducible factor 1 alpha (HIF1α) that preceded adhesion development. Inhibition of HIF1α with small molecules ameliorated the injury program in damaged mesothelium and was sufficient to diminish adhesion severity in a mouse model. Analyses of human adhesion tissue suggested that similar surface markers and signaling pathways may contribute to surgical adhesions in human patients.

Viable cryopreserved umbilical tissue (vCUT) reduces post-operative adhesions in a rabbit abdominal adhesion model

Post-operative adhesions, a common complication of surgery, cause pain, impair organ functionality, and often require additional surgical interventions. Control of inflammation, protection of injured tissue, and rapid tissue repair are critical for adhesion prevention. Adhesion barriers are biomaterials used to prevent adhesions by physical separation of opposing injured tissues. Current adhesion barriers have poor anti-inflammatory and tissue regenerative properties. Umbilical cord tissue (UT), a part of the placenta, is inherently soft, conforming, biocompatible, and biodegradable, with antimicrobial, anti-inflammatory, and antifibrotic properties, making it an attractive alternative to currently available adhesion barriers. While use of fresh tissue is preferable, availability and short storage time limit its clinical use. A viable cryopreserved UT (vCUT) "point of care" allograft has recently become available. vCUT retains the extracellular matrix, growth factors, and native viable cells with the added advantage of a long shelf life at -80 °C. In this study, vCUT's anti-adhesion property was evaluated in a rabbit abdominal adhesion model. The cecum was abraded on two opposing sides, and vCUT was sutured to the abdominal wall on the treatment side; whereas the contralateral side of the abdomen served as an internal untreated control. Gross and histological evaluation was performed at 7, 28, and 67 days post-surgery. No adhesions were detectable on the vCUT treated side at all time points. Histological scores for adhesion, inflammation, and fibrosis were lower on the vCUT treated side as compared to the control side. In conclusion, the data supports the use of vCUT as an adhesion barrier in surgical procedures.

Implementation of an adhesive small bowel obstruction protocol using low-osmolar water soluble contrast and the impact on patient outcomes

BACKGROUND

Small bowel obstruction (SBO) is a common condition leading to numerous hospital admissions and operations. Standardized care of adhesive SBO patients has not been widely implemented in hospital systems.

METHODS

A prospective cohort of SBO patients was compared to a historical cohort of SBO patients after implementation of a SBO protocol using evidence-based guidelines and Omnipaque, a low-osmolar water soluble contrast. Patients without a history of abdominal surgery were excluded and data was collected through chart review.

RESULTS

Univariate analyses demonstrated a decrease in both LOS by 1.35 days and in the proportion of patients receiving surgery (37% vs 25%; p < 0.05). There was a decrease in time to surgery, rate of SBR, and rate of complications, yet an increase in readmission, although these findings were not statistically significant.

CONCLUSIONS

Utilizing an evidence-based SBO protocol can lead to shorter LOS and may result in fewer operations for adhesive SBO patients.

Evaluation of the effects of adipose-derived mesenchymal stem cells on intraperitoneal adhesions

OBJECTIVES

The goal was to examine the efficiency of local implementation of adipose-derived mesenchymal stem cells, which have an anti-inflammatory effect, in preventing the intra-abdominal adhesions in rats.

MATERIAL AND METHODS

Twenty-one Wistar albino rats were randomly divided into 3 groups, 7 rats in each: Group 1 was defined as the control group, Group 2 as the sham group, and Group 3 as the adipose-derived mesenchymal stem cell group. A 6 cm mid-abdomen incision in the all the rats was performed. The cecum serosa and sub-serosa were injured by rubbing with a gauze. No agent was applied intraperitoneally for the rats in Group 1; 1.5 mL saline and 2x10⁶/kg allojenic adipose-derived mesenchymal stem cells in the 1.5 mL saline were injected into peritoneum of rats in Groups 2 and 3, respectively. Laparotomy was performed on the 14^th day. Adhesion scores, histopathological examination, E-cadherin expression, and the tissue hydroxyproline level were evaluated.

RESULTS

The general adhesion score and collagen deposition in Group 3 were found to be significantly higher than in Groups 1 and 2 (p=0.003 and p=0.009, respectively). In the inflammatory cell comparison, a significant decrease was found in Group 3 in proportion to Groups 1 and 2 (p=0.001, p=0.005, respectively). The E-cadherin levels were found to be higher in Group 3 (p=0.003).

CONCLUSION

Severe adhesion was observed in the adipose-derived mesenchymal stem cells group. Collagen intensity and E-Cadherin expression also increased in the adipose-derived mesenchymal stem cells group. The anti-inflammatory effect was also seen in the adipose-derived mesenchymal stem cells group.

Managing Adhesive Small Bowel Obstruction with Water-Soluble Contrast Should Be Protocolized: A Retrospective Analysis

Aim  Current literature emphasizes the effectiveness of computed tomography (CT) and water-soluble contrast agent, Gastrografin, in the investigation of adhesive small bowel obstruction (ASBO). As there is no management protocol for ASBO at our institution, the aim of this study was to determine the effect of imaging methods—CT, Gastrografin challenge (GC), or plain-film X-ray—on patient outcomes in a clinical setting.

Methods  All 163 emergency presentations of ASBO during the study period between December 2010 and September 2012 were collected retrospectively. Cases were divided into three groups: CT with oral contrast, GC, or plain-film X-ray only. The primary outcome was time to theater.

Results  Patients investigated with X-ray only were significantly less likely to require surgery (6% in plain-film X-ray vs. 35% and 20% in CT and GC, respectively; p  = 0.003). In cases requiring surgery, GC was associated with a 24-hour longer time to imaging than CT ( p  < 0.001). The time to theater was 71:25 hours for GC versus 46:39 for CT ( p  = 0.039). There was no significant difference in bowel resection or complication rates.

Conclusion  Patients undergoing water-soluble contrast studies were subjected to unnecessary delays in their clinical course. These delays are costly and avoidable. The development and implementation of an evidence-based protocol for the management of small bowel obstruction is strongly recommended. The lack of a protocol likely caused significant delays in Gastrografin administration, reducing its known benefits for clinical decision-making and length of stay.

Baseline performance of the ischaemic button model for induction of adhesions in laboratory rats

The ischaemic button model is frequently used for the induction of adhesions in laboratory rats. Male rats are often used because of the common belief that the peritesticular (intra-abdominal) fat in males facilitates adhesion formation, although this theory is not evidence based. Comparing the model’s performance in both sexes is an important aspect of refining animal experiments. The aim of this study is to compare baseline performance of the modified ischaemic button model in both male and female rats. Follow-up was 1 week and noted endpoints were intra-abdominal adhesion formation and differences in welfare assessment. A total of 192 ischaemic buttons (96 male/96 female) were created in 24 Wistar Han rats (12 male/12 female). After 1 week of follow-up, 93 buttons survived in the male group (96.9%) compared with 91 in the female group (94.8%) (p = 0.409). In the male group, 85 out of 93 (91.4%) buttons induced adhesions compared with 84 out of 91 (92.3%) in the female group (p = 0.881). All but one animal had a Zühlke score of 3. There were no clinically relevant differences in welfare scores. Male animals increased in weight significantly faster compared to females (p < 0.001), after correcting for physiological growth. The ischaemic button model resulted in equal quality and quantity of intra-abdominal adhesions in both male and female Wistar Han rats. Both male and female Wistar Han rats are suitable for the induction of experimental adhesions in the ischaemic button model.

Current management of adhesive small bowel obstruction

Small bowel obstruction is a common and significant surgical presentation. Approximately 30% of presentations will require surgery during admission. The great challenge of adhesive small bowel obstruction (ASBO) management is the early detection of silent intestinal ischaemia in patients initially deemed suitable for conservative therapy. Recent literature emphasizes the effectiveness of computed tomography enterography and water-soluble contrast studies in the management of ASBO. Low-volume undiluted water-soluble contrast has been shown to have both triage and therapeutic value in the management of ASBO. Their use has been demonstrated to reduce the need for surgery to below 20%. There has also been growing interest in clinicoradiological algorithms which aim to predict ischaemia early in the course of presentation. The aim of this review is to summarize the latest evidence and clarify previous uncertainties, specifically regarding the duration of conservative treatment, timing of contrast studies and the reliability of predictive algorithms. Based on this latest evidence, we have formulated a management protocol which aims to integrate these latest developments and formalize a strategy for best management in ASBO.

Effect of 4DryField® PH, a Novel Adhesion Barrier, on Recurrence of Intestinal Adhesions after Extensive Visceral Adhesiolysis

Background

Adhesions occur after up to 97% of abdominal interventions causing chronic pain, infertility, and intestinal obstruction. Various concepts to prevent adhesions have been presented but mostly either have low efficacy or are not applicable in resective intestinal surgery or incomplete hemostasis. In this retrospective one-center clinical trial, the course of patients with extensive abdominal adhesiolysis and application of a recent starch-based formulation, 4DryField PH (4DF), is analyzed.

Case Report

Five female patients (age 65–83 years) underwent extensive open adhesiolysis with application of 4DF gel for adhesion prevention, premixed extracorporeally with saline or Ringer's solution (60–70 mL per 5 g 4DF) for homogeneous gel distribution on intestinal loops and in the peritoneal cavity. In addition, dry 4DF powder was dispersed on the greater omentum and subsequently transformed into a gel by dripping with saline or Ringer's solution directly before abdominal closure. Patients were followed up for more than two years, except for one patient who died after nine months due to metastases. One patient with complex situation due to Gore-Tex mesh in the lower abdomen showed no adhesions at scheduled second-look operation but after six months had relaparotomy for adhesiolysis. All other patients have remained free of adhesions or adhesion-related symptoms during follow-up.

Conclusion

Considering the extent and complexity of adhesions, treatment with 4DF gel for adhesion prevention after open adhesiolysis appears promising. Prospective randomized trials should further elaborate on this clinical concept.

Relationship between duration of preoperative symptoms and postoperative ileus for small bowel obstruction

BACKGROUND

Factors associated with postoperative ileus and increased resource utilization for patients who undergo operative intervention for small-bowel obstruction are not extensively studied. We evaluated the association between total duration of preoperative symptoms and postoperative outcomes in this population.

MATERIALS AND METHODS

We performed a retrospective review of patients who underwent surgery for small-bowel obstruction (2013-2016). Clinical data were recorded. Total duration of preoperative symptoms included all symptoms before operation, including those before presentation. Primary endpoint was time to tolerance of diet. Secondary endpoints included length of stay, total parenteral nutrition use, and intensive care unit admission. Association between variables and outcomes was analyzed using univariable analysis, multivariable Poisson modeling, and t-test to compare groups.

RESULTS

Sixty-seven patients were included. On presentation, the median duration of symptoms before hospitalization was 2 d (range 0-18 d). Total duration of preoperative symptoms was associated with time to tolerance of diet on univariable analysis (Pearson's moment correlation: 0.28, 95% confidence interval: 0.028-0.5, P = 0.03). On multivariable analysis, ascites was correlated with time to tolerance of diet (P < 0.01), but total duration of preoperative symptoms (P = 0.07) was not. Length of stay (Pearson's correlation: 0.24, 95% confidence interval: -0.02 to 0.47, P = 0.07) was not statistically different in patients with longer preoperative symptoms. Symptom duration was not statistically associated with intensive care unit (P = 0.18) or total parenteral nutrition (P = 0.3) utilization.

CONCLUSIONS

Our findings demonstrate that preoperative ascites correlated with increased time to tolerance of diet, and duration of preoperative symptoms may be related to postoperative ileus.

A systematic review and overview of health economic evaluations of emergency laparotomy

Background

Little is known about the economic impact of emergency laparotomy (EL) surgery in healthcare systems around the world. The aim of this systematic review is to describe the primary resource utilisation, healthcare economic and societal costs of EL in adults in different countries.

Methods

MEDLINE, EMBASE, ISI Web of Knowledge, Cochrane Central Register Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were searched for full and partial economic analyses of EL published between 1 January 1991 and 31 December 2015. Quality of studies was assessed using the Consensus on Health Economic Criteria (CHEC) checklist.

Results

Sixteen studies were included from a range of countries. One study was a full economic analysis. Fifteen studies were partial economic evaluations. These studies revealed that emergency abdominal surgery is expensive compared to similar elective surgery when comparing primary resource utilisation costs, with an important societal impact. Most contemporaneous studies indicate that in-hospital costs for EL are in excess of US$10,000 per patient episode, rising substantially when societal costs are considered.

Discussion

EL is a high-risk and costly procedure with a disproportionate financial burden for healthcare providers, relative to national funding provisions and wider societal cost impact. There is substantial heterogeneity in the methodologies and quality of published economic evaluations of EL; therefore, the true economic costs of EL are yet to be fully defined. Future research should focus on developing strategies to embed health economic evaluations within national programmes aiming to improve EL care, including developing the required measures and infrastructure.

Conclusions

Emergency laparotomy is expensive, with a significant cost burden to healthcare and systems and society worldwide. Novel strategies for reducing this econmic burden should urgently be explored if greater access to this type of surgery is to be pursued as a global health target.

Trial registration

PROSPERO registration no. 42015027210.

Sutures impregnated with carbazate-activated polyvinyl alcohol reduce intraperitoneal adhesions

BACKGROUND

Intraperitoneal adhesions cause significant morbidity. They occur after peritoneal trauma, which induces oxidative stress with production of inflammatory cytokines, peroxidized proteins (carbonyls) and lipids (aldehydes). This study aimed to investigate if carbazate-activated polyvinyl alcohol (PVAC), an aldehyde-carbonyl inhibitor, can reduce intraperitoneal adhesions in an experimental model.

MATERIAL AND METHODS

Male Sprague-Dawley rats (n=110) underwent laparotomy, cecal abrasion and construction of a small bowel anastomosis. They either were treated with intraperitoneal instillation of PVAC or were sutured with PVAC-impregnated sutures. Thromboelastography analysis was performed using human blood and PVAC. The lipid peroxidation product malondialdehyde (MDA) and inflammatory cytokines IL-1β and IL-6 were quantified in peritoneal fluid. At day 7, bursting pressure of the anastomosis was measured and adhesions were blindly scored.

RESULTS

PVAC in human blood decreased the production of the fibrin-thrombocyte mesh without affecting the coagulation cascade. MDA, IL-1β and IL-6 were increased after 6h without significant difference between the groups. PVAC-impregnated sutures reduced intraperitoneal adhesions compared to controls (p=0.0406) while intraperitoneal instillation of PVAC had no effect. Anastomotic bursting pressure was unchanged.

CONCLUSIONS

Intervention with an aldehyde-carbonyl inhibitor locally in the wound by PVAC-impregnated sutures might be a new strategy to reduce intraperitoneal adhesions.

Postoperative Abdominal Adhesions: Clinical Significance and Advances in Prevention and Management

Postoperative adhesions remain one of the more challenging issues in surgical practice. Although peritoneal adhesions occur after every abdominal operation, the density, time interval to develop symptoms, and clinical presentation are highly variable with no predictable patterns. Numerous studies have investigated the pathophysiology of postoperative adhesions both in vitro and in vivo. Factors such as type and location of adhesions, as well as timing and recurrence of adhesive obstruction remain unpredictable and poorly understood. Although the majority of postoperative adhesions are clinically silent, the consequences of adhesion formation can represent a lifelong problem including chronic abdominal pain, recurrent intestinal obstruction requiring multiple hospitalizations, and infertility. Moreover, adhesive disease can become a chronic medical condition with significant morbidity and no effective therapy. Despite recent advances in surgical techniques, there is no reliable strategy to manage postoperative adhesions. We herein review the pathophysiology and clinical significance of postoperative adhesions while highlighting current techniques of prevention and treatment.

Value of gastrografin in adhesive small bowel obstruction

BACKGROUND

Small bowel obstruction (SBO) from adhesive disease presents great burden for the healthcare system. Some groups have reported water soluble contrast agents (WSCA) protocols, but published studies are underpowered. This study introduces a WSCA protocol to improve outcomes and streamline patient care.

STUDY DESIGN

The study ran July 1, 2013-June 30, 2015, at Kaiser Permanente San Diego; protocol started July 1, 2014. Data was collected prospectively, on an intention to treat basis. We excluded patients whose SBO were not due to adhesive disease. Protocol included nasogastric tube, intravenous resuscitation, liquid docusate, and gastrografin study if symptoms persisted at 24 h. Colon contrast determined resolution vs operative consideration. Primary outcomes were operative rates and hospital length of stay (LOS).

RESULTS

Seven hundred fifteen were patients admitted with SBO; after exclusions there were 261 pre-protocol and 243 protocol patients. One hundred sixty patients resolved within 24 h; 96% of remaining patients stayed on protocol (n = 154). After WSCA protocol began, 15.6% required an operation, compared to 19.8% of pre-protocol patients (NS). The WSCA protocol significantly decreased the time to surgery (2.8 vs 4.88 days, p = 0.03), and the LOS of operated patients (9.51 vs 15.78 days, p = 0.02).

CONCLUSIONS

A standardized SBO protocol using WSCA significantly decreased time to operation and hospital LOS. This approach improves utilization of resources and may improve outcomes. More work should be done to investigate the positive effects of WSCA protocol for patients with SBO.

Surgeon attitudes and practice patterns in managing small bowel obstruction: a qualitative analysis

BACKGROUND

Historical training instructs surgeons to, "never let the sun set on a small bowel obstruction (SBO)" due to concern for bowel ischemia. However, the routine use of computed tomography scans for ruling out ischemia provides the opportunity for trial of nonoperative management, allowing time for resolution of adhesive SBO. In light of advances in practice, little is known about how surgeons manage these patients, in particular, whether there is consistency in the stated duration for safe nonoperative management.

METHODS

Using a case vignette (a patient with computed tomography scan diagnosed complete SBO without bowel ischemia), we interviewed a purposive sample of general surgeons practicing in Washington State to understand stated approaches to clinical management. Interview questions addressed typical practice, preferred timing of surgery, and approach. We conducted a content analysis to understand current practice and attitudes.

RESULTS

We interviewed 15 surgeons practicing across Washington State. Surgical practice patterns for patients with SBO varied widely. The period of time that surgeons were willing to manage patients nonoperatively ranged from 1-7 d. Interviews revealed insight into surgical decision-making, the importance of patient preferences, variation in practice, and evidence gaps. All surgeons acknowledged a lack of evidence to support appropriate management of patients with SBO.

CONCLUSIONS

Interviews with practicing surgeons highlight a changing paradigm away from routine early surgery for patients with adhesive SBO. However, there is lack of consensus in the appropriate duration of nonoperative management and practices vary considerably. These revealed attitudes inform the feasibility and design of future randomized studies of patients with adhesive SBO.

A novel diagnostic aid for intra-abdominal adhesion detection in cine-MRI: pilot study and initial diagnostic impressions

OBJECTIVE

A non-invasive diagnostic technique for abdominal adhesions is not currently available. Capture of abdominal motion due to respiration in cine-MRI has shown promise, but is difficult to interpret. This article explores the value of a complimentary diagnostic aid to facilitate the non-invasive detection of abdominal adhesions using cine-MRI.

METHOD

An image processing technique was developed to quantify the amount of sliding that occurs between the organs of the abdomen and the abdominal wall in sagittal cine-MRI slices. The technique produces a "sheargram" which depicts the amount of sliding which has occurred over 1-3 respiratory cycles. A retrospective cohort of 52 patients, scanned for suspected adhesions, made 281 cine-MRI sagittal slices available for processing. The resulting sheargrams were reported by two operators and compared with expert clinical judgment of the cine-MRI scans.

RESULTS

The sheargram matched clinical judgment in 84% of all sagittal slices and 93-96% of positive adhesions were identified on the sheargram. The sheargram displayed a slight skew towards sensitivity over specificity, with a high positive adhesion detection rate but at the expense of false positives.

CONCLUSION

Good correlation between sheargram and absence/presence of inferred adhesions indicates quantification of sliding motion has potential to aid adhesion detection in cine-MRI.

ADVANCES IN KNOWLEDGE

This is the first attempt to clinically evaluate a novel image processing technique quantifying the sliding motion of the abdominal contents against the abdominal wall. The results of this pilot study reveal its potential as a diagnostic aid for detection of abdominal adhesions.

Evaluation of botulinum toxin type A effectiveness in preventing postoperative intraperitoneal adhesions

Purpose

Postoperative intraperitoneal adhesions (PIAs) are one of the most important problems surgeons have to face after laparotomies. In this study, we aimed to evaluate the effectiveness of local application of botulinum toxin type A (BoNT-A) in various dosages on the prevention of intra-abdominal adhesions in rats with experimental intra-abdominal adhesions.

Methods

Forty Wistar Albino female rats were randomly separated into 4 groups. The 4 groups were determined as follows: Control (group 1, n = 10); Sham (group 2, n = 10); 10-µg/kg low-dose BoNT-A (group 3, n = 10) and 30-µg/kg high-dose BoNT-A (group 4, n = 10). Subserosal injuries were created on the caecum of all rats. Laparotomy was performed on the fifth day. Adhesion scores, histopathological examination, and E-cadherin expression levels were evaluated.

Results

General adhesion scores for groups 1 and 2 were determined to be significantly high when compared to group 4 (P < 0.001). A significant difference was also determined between groups 3 and 4 in terms of general adhesion scores (P < 0.05). In pair comparisons, a significant decrease in high-dose BoNT-A group (group 4) when compared to groups 1 and 2 in terms of neovascularization, fibroblast density, collagen deposition and inflammatory cell count was determined (P < 0.05).

Conclusion

A significant decrease was observed only in postoperative PIAs in the high-dose BoNT-A group between all 4 rat-groups with experimentally created postoperative PIAs. In this study, high-dose BoNT-A is determined to be an effective agent in preventing postoperative PIAs.

A Systematic Review of the Clinical Presentation, Diagnosis, and Treatment of Small Bowel Obstruction

PURPOSE OF REVIEW

This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy.

RECENT FINDINGS

SBO incidence is about 350,000/annum in the USA. Etiologies include adhesions (65%), hernias (10%), neoplasms (5%), Crohn's disease (5%), and other (15%). Bowel dilatation occurs proximal to obstruction primarily from swallowed air and secondarily from intraluminal fluid accumulation. Dilatation increases mural tension, decreases mucosal perfusion, causes bacterial proliferation, and decreases mural tensile strength that increases bowel perforation risks. Classical clinical tetrad is abdominal pain, nausea and emesis, abdominal distention, and constipation-to-obstipation. Physical exam may reveal restlessness, acute illness, and signs of dehydration and sepsis, including tachycardia, pyrexia, dry mucous membranes, hypotension/orthostasis, abdominal distention, and hypoactive bowel sounds. Severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness suggest advanced SBO, as do marked leukocytosis, neutrophilia, bandemia, and lactic acidosis. Differential diagnosis includes postoperative ileus, narcotic bowel, colonic pseudo-obstruction, mesenteric ischemia, and large bowel obstruction. Medical resuscitation includes intravenous hydration, correcting electrolyte abnormalities, intravenous antibiotics, nil per os, and nasoenteral suction. Abdominal CT with oral and intravenous gastrografin contrast is highly sensitive and specific in detecting/characterizing SBO. SBO usually resolves with medical therapy but requires surgery, preferentially by laparoscopy, for unremitting total obstruction, bowel perforation, severe ischemia, or clinical deterioration with medical therapy. Overall mortality is 10% but increases to 30% with bowel necrosis/perforation. Key point in SBO is early diagnosis, emphasizing abdominal CT; aggressive medical therapy including rehydration, antibiotics, and nil per os; and surgery for failed medical therapy.

Anti-adhesive effects of a newly developed two-layered gelatin sheet in dogs

Aim

Adhesion after pelvic surgery causes infertility, ectopic pregnancy, and ileus or abdominal pain. The materials currently available for clinical use are insufficient. The purpose of this study was to develop an anti‐adhesive material that overcomes the limitations of conventional anti‐adhesive agents.

Methods

The adhesion prevention effects of three methods – a two‐layered sheet composed of gelatin film and gelatin sponge, Seprafilm and INTERCEED – were evaluated in 37 dogs. Anti‐adhesive effects were investigated macroscopically and microscopically in a cauterized uterus adhesion model. Cell growth on the materials in vitro using human peritoneal mesothelial cells, fibroblasts and uterine smooth muscle cells were also evaluated.

Results

The two‐layered gelatin sheet had significantly superior anti‐adhesive effects compared to the conventional materials (Seprafilm and INTERCEED). A single‐cell layer of mature mesothelium formed three weeks after surgery in the gelatin group. Peritoneum regeneration in the Seprafilm and INTERCEED groups was delayed and incomplete in the early phase. Little inflammation around the materials occurred and cell growth was significantly proliferated with the gelatin sheet.

Conclusion

The anti‐adhesive effects of a two‐layered gelatin sheet were superior to conventional agents in a cauterized canine uterus model, demonstrating early regeneration of the peritoneum, little inflammation and material endurance. The newly developed two‐layered gelatin sheet is a useful option as an anti‐adhesive agent for deeply injured and hemorrhagic sites.

Benefit of an implanted solid barrier for the feasibility of a sequence of three different hepato-biliary operations in a small animal model

BACKGROUND

Current liver surgery includes complex multi-stage procedures such as portal vein ligation (PVL) followed by extended liver resection, especially in patients with Klatskin tumours. The risk for severe adhesions increases with every procedure. Finally, this complex sequence could fail because of malignant adhesions. Therefore, we proved the hypothesis of reducing malignant adhesions and increasing feasibility of a sequence with three hepato-biliary operations by implantation of a solid barrier.

MATERIALS AND METHODS

We operated in male rats (n=40). Our sequence included as 1st operation bile duct ligation mimicking Klatskin III° or IV°, the 2nd operation was a selective portal vein ligation (sPVL) and 3rd procedure was a 70% liver resection. The mechanical barrier (part of a sterile glove) was implanted at the end of the first operation between the upper (median lobe+left lateral lobe [ML+LLL]) and lower (right lobe+caudate lobe [RL+CL]) rat liver lobes. We assessed the degree of adhesions and the feasibility of the 2nd and 3rd operation by using an established adhesion score (Zühlke) and a feasibility score. The severity of the adhesions and the pro-inflammatory cellular response were further evaluated by morphometry of thickness (HE) of the adhesion layer and quantification of infiltrating neutrophils (ASDCL) in the adhesion layer on the liver surface.

RESULTS

The planned liver resection as the third procedure was only feasible when a mechanical barrier was placed. Extent of cholestasis or time interval between the operations had no significant impact on adhesions score or feasibility of the whole sequence.

CONCLUSION

A sequence of three hepato-biliary operations in a small animal model (rat) is feasible. It should be considered to implant a mechanical barrier in a sequence of more than two surgical interventions in an experimental model in order to assure the feasibility of the final operation.