Complications and death after surgical treatment of small bowel obstruction: A 35-year institutional experience

New insertion method of transnasal ileus tube for small bowel obstruction: Anterior balloon method

Background

Small bowel obstruction (SBO) is usually caused by postoperative adhesions and malignant disease, and decompression is effective for SBO. Our previous case report suggested that a new transnasal ileus tube insertion method, the anterior balloon method (ABM), could achieve decompression for adhesive SBO.

Aims

The study aimed to investigate the effectiveness of a new method for inserting transnasal ileus tubes in patients with SBO.

Methods

Altogether, 134 patients with small bowel obstruction treated from January 2011 to December 2017 were reviewed. The patients were categorized into two groups: those with the new method that inserts an anterior balloon (ABM group: 52 patients, 2014–2017) versus those with the ordinary insertion method (OIM group: 82 patients, 2011–2014).

Results

The patients’ characteristics and symptoms on admission were similar in the ABM and OIM groups. Adhesions were the main cause of ileus in the two groups. The insertion time duration was significantly shorter in the ABM group than in OIM group (28.4 ± 9.1 vs. 33.5 ± 13.0 min; p = 0.01). The ABM group also had significantly longer tubes than OIM group (222.4 ± 32.2 vs. 157.4 ± 31.7 cm; p < 0.001), which resulted in a significantly shorter time until clinical symptoms were relieved in ABM group. There were no significant differences in adverse events between the two groups.

Conclusions

The ABM group had shorter insertion duration and longer tubes than those of OIM group. The ABM might become a preferred therapeutic choice to achieve decompression in patients with SBO.

Small Bowel Obstruction

Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.

Association between Abdominal Free Fluid and Postoperative Complications and Mortality in Patients with Small-Bowel Obstruction

BACKGROUND AND AIMS:

Small-bowel obstruction is a frequent cause of hospitalization. The condition is potentially life-threatening, causing many admission days and is a heavy burden socioeconomically. Patients with small-bowel obstruction may develop abdominal free fluid and the quality of this fluid may be predictive of worse outcomes. Our aim was to examine whether the presence of free fluid and its density, measured on computed tomography scans, was associated with severe complications and mortality postoperatively.

MATERIALS AND METHODS:

Patients admitted to the Department of Surgery, Zealand University Hospital with a diagnosis of small-bowel obstruction between January 2010 and December 2015 were included. Medical records were reviewed and preoperative computed tomography scans were examined. A radiologist blinded to the outcomes reviewed all Hounsfield unit values of the free fluid. The primary outcomes evaluated were odds ratios of the severity of complications and hazard ratios of 30- and 90-day mortality postoperatively.

RESULTS:

A total of 289 patients were included. Analyses revealed an adjusted odds ratio of 1.03 (95%confidence interval = 0.93-1.15) between the presence of free fluid and postoperative complications and an adjusted hazard ratio of 1.28 (95% confidence interval =  0.80-2.05, p = 0.30) of the 30-day mortality in this patient group. Furthermore, the analyses revealed an adjusted odds ratio of 1.22 (95% confidence interval 0.98-1.52) between the density of the free fluid > 20 Hounsfield unit and postoperative complications and an adjusted hazard ratio of 0.85 (95% confidence interval =  0.28-2.63, p = 0.78) of the 30-day mortality.

CONCLUSION:

No significant correlation was found between the presence of free fluid nor its density in regard to postoperative complications or mortality in patients with small-bowel obstruction.

A Prediction Model for Recognizing Strangulated Small Bowel Obstruction

Introduction

Early and accurate diagnosis of strangulated small bowel obstruction (SSBO) is difficult. This study aimed to devise a prediction model for predicting the risk of SSBO.

Materials and Methods

A database of 417 patients who had clinical symptoms of intestinal obstruction confirmed by computed tomography (CT) were evaluated for inclusion in this study. Symptoms and laboratory and radiologic findings of these patients were collected after admission. These clinical factors were analyzed using logistic regression. A logistic regression model was applied to identify determinant variables and construct a clinical score that would predict SSBO.

Results

Seventy-six patients were confirmed to have SSBO, 169 patients required surgery but had no evidence of intestinal ischemia, and 172 patients were successfully managed conservatively. In multivariate logistic regression analysis, body temperature ≥ 38.0°C, positive peritoneal irritation sign, white blood cell (WBC) count > 10.0 × 10^9/L, thick-walled small bowel ≥3 mm, and ascites were significantly associated with SSBO. A new prediction model with total scores ranging from 0 to 481 was developed with these five variables. The area under the curve (AUC) of the new prediction model was 0.935.

Conclusions

Our prediction model is a good predictive model to evaluate the severity of SBO.

Assessment of Strangulation in Adhesive Small Bowel Obstruction on the Basis of Combined CT Findings: Implications for Clinical Care

Purpose To determine which computed tomography (CT) findings or combinations of findings can help to accurately identify strangulation in adhesive small bowel obstruction (SBO). Materials and Methods Contrast agent-enhanced CT findings in a cohort of 256 patients consecutively admitted for adhesive SBO, with a delay of less than 24 hours between CT and surgery for the operated patients, were reviewed independently by two radiologists, with consensus by a third, to assess CT findings commonly associated with strangulation. The reference standard for strangulation was surgery. Univariate and multivariate analyses were performed to identify predictors of strangulation in the entire cohort and to identify predictors of the need for surgical resection in the subgroup of patients with strangulation. A CT score was obtained and diagnostic performances of different combined CT findings were calculated. Results In this study, 105 patients (41.0%; 105 of 256) underwent a surgical procedure, 62 of whom were found to have strangulation (59.0%; 62 of 105), whereas 151 patients (59.0%; 151 of 256) improved with medical care. Three CT findings were significantly associated with strangulation in the multivariate analysis: reduced bowel wall enhancement (odds ratio, 7.8; 95% confidence interval [CI]: 2.6, 23.5), diffuse mesenteric haziness (odds ratio, 6.1; 95% CI: 2.5, 15.2), and a closed-loop mechanism (odds ratio, 6.5; 95% CI: 2.8, 15.5). The model combining these three features had an area under the curve of 0.91 (95% CI: 0.86, 0.96) and a high negative predictive value (97%; 95% CI: 93%, 99%). Positive likelihood ratios were high when two or three of these CT findings were combined (positive likelihood ratios, 14.7 [95% CI: 7.1, 30.4] and 43.8 (95% CI: 14.2, 135.2], respectively). Among the strangulated cases, reduced bowel wall enhancement (odds ratio, 3.9; 95% CI: 1.3, 12) and mesenteric fluid (odds ratio, 3.6; 95% CI: 1.0, 12.8) were predictive of resection. Conclusion A score that combines three CT findings (reduced bowel wall enhancement, a closed-loop mechanism, and diffuse mesenteric haziness) can accurately predict strangulation in adhesive SBO. ^© RSNA, 2017 Online supplemental material is available for this article.

Defining the Need for Surgery in Small-Bowel Obstruction

BACKGROUND

Small-bowel obstruction is a frequent disorder in emergency medicine and represents a major burden for patients and health care systems worldwide. Within the past years, progress has been made regarding the management of small-bowel obstructions, including the use of contrast agent swallow as a tool in the decision-making process.

OBJECTIVES

This is a prospective controlled study investigating the central role of contrast agent swallow in the diagnostic and treatment algorithm for small-bowel obstruction at a university department of surgery. Endpoints were the correct identification of patients who needed operative treatment and the accuracy of a conservative treatment decision including the analysis of dropout from this routine algorithm.

METHODS

We performed a single-center analysis of 181 consecutive patients diagnosed with a small-bowel obstruction based on clinical, radiologic, and sonographic findings. Patients with clinical signs of strangulation or peritonitis underwent immediate surgery (group 1). Patients without signs of peritonitis and incomplete stop in the initial abdominal plain film were considered eligible for Gastrografin® challenge (group 2).

RESULTS

Seventy-six of the 181 patients (42.0%) underwent immediate surgery. A Gastrografin® challenge was initialized in 105 of the 181 patients (58.0%). Twenty of these 105 patients (19.1%) with persisting or progressive symptoms and absence of contrast agent in the colon after 12 and 24 h subsequently underwent surgery. Here, a segmental bowel resection was necessary in 6 of these 20 patients (30.0%). In 16 out of 20 patients (80.0%) who failed the Gastrografin® challenge, a corresponding correlate in terms of a strangulation was detected intraoperatively. The Gastrografin® challenge had a specificity of 96% and a sensitivity of 100%; accuracy to predict the need for exploration was 96%.

CONCLUSION

A straightforward algorithm based mainly on contrast agent swallow for patients with small-bowel obstructions enabled a timely and very accurate differentiation between patients qualifying for conservative and operative treatment.

Outcomes After Surgery for Benign and Malignant Small Bowel Obstruction

BACKGROUND

Small bowel obstruction (SBO) is a common diagnosis; however, outcomes of and risk factors for SBO and malignant bowel obstruction (MBO) surgery are not well understood. We sought to characterize outcomes and risk factors for surgery for SBO and MBO.

METHODS

A retrospective cohort study was performed utilizing prospectively collected data from the Michigan Surgical Quality Collaborative (7/2012-3/2015). Cases included those with ICD9 diagnosis code of bowel obstruction and CPT codes for lysis of adhesions, intestinal bypass, and small bowel resection. Cases were stratified by disseminated malignancy (MBO). Factors associated with complications and 30-day mortality were evaluated.

RESULTS

Two thousand two hundred thirty-three patients underwent surgery for bowel obstruction, including 86 patients (3.9 %) with MBO. MBO patients had an adjusted mortality rate of 14.5 % (benign 5.0 %); the adjusted complication rate was 32.2 % (benign 27.0 %). Factors independently associated with mortality included disseminated cancer, older age, American Society of Anesthesiologists IV/V, cirrhosis, ascites, urinary tract infection, sepsis, albumin <3.5, hematocrit <30, and bowel resection.

CONCLUSIONS

Surgery for bowel obstruction carries a relatively high risk for morbidity and mortality, particularly in patients with malignant bowel obstruction. Considering the identified risk factors for mortality may help clinicians make recommendations regarding surgery in the setting of MBO.

Congenital adhesion band causing small bowel obstruction: What's the difference in various age groups, pediatric and adult patients?

BACKGROUND

A congenital adhesion band is a rare condition, but may induce a small bowel obstruction (SBO) at any age. However, only a few sporadic case reports exit. We aimed to identify the clinical characteristics of congenital adhesion band manifesting a SBO stratified by age group between pediatric and adult patients.

METHODS

The medical records of all patients with a SBO between Jan 1, 2009 and Dec 31, 2015 were retrospectively reviewed. Cases associated with previous surgical procedure and cases of secondary obstruction due to inflammatory processes or tumor and other systemic diseases were excluded. The patients were divided into two groups according to age below or above 18 years: pediatric and adult. The basic clinical characteristics were analyzed and compared between groups.

RESULTS

Of 251 patients with a SBO, 15 (5.9%) met the inclusion criteria; 10 cases in pediatric group (mean age 17.9 ± 38.7 months) and 5 cases in adult group (mean age 60.0 ± 19.7 years). The pediatric group (66.6%) included 3 neonates, 5 infants, and 2 school children. They usually presented with bilious vomiting (50.0%) and abdominal distention (60.0%), and demonstrated a high rate of early operation (80.0%) and bowel resection (70.0%). In contrast, the adult group (33.3%) presented with abdominal pain (100%) in all cases and underwent a relatively simple procedure of band release using a laparoscopic approach (60%). However, group differences did not reach statistical significance. In addition, two groups did not differ in the time interval to the operation or in the range of the operation (p = 0.089 vs. p = 0.329). No significant correlation was found between the time interval to the operation and the necessity of bowel resection (p = 0.136). There was no mortality in either group.

CONCLUSIONS

Congenital adhesion band is a very rare condition with diverse clinical presentations across ages. Unlike adult patients, pediatric patients showed a high proportion of early operation and bowel resection. A good result can be expected with an early diagnosis and prompt management regardless of age.

High-Density Free Fluid on Computed Tomography: a Predictor of Surgical Intervention in Patients with Adhesive Small Bowel Obstruction

BACKGROUND

Patients with adhesive small bowel obstruction (ASBO) often develop intraabdominal free fluid (IFF). While IFF is a finding on abdominopelvic computed tomography (CT) associated with the need for surgical intervention, many patients with IFF can be still managed non-operatively. A previous study suggested that a higher red blood cell count of IFF is highly predictive of strangulated ASBO. We hypothesized that radiodensity in IFF (Hounsfield unit (HU)) on CT would predict the need for surgical intervention.

STUDY DESIGN

Patients with clinicoradiological evidence of ASBO between January 2009 and December 2013 were identified. In patients with IFF > 3 cm² identified on CT, the HU was measured in the largest pocket of IFF. A sensitivity analysis was performed to determine a high-density HU threshold. The HU of patients who underwent therapeutic laparotomy was compared with those successfully discharged with non-operative management.

RESULTS

A total of 318 patients with ASBO (median age 52 years, 56.0 % male) were identified. Of 111 patients who had IFF on CT, 55.9 % underwent therapeutic laparotomy and 15.3 % required bowel resection. Radiodensity of IFF in the operative group was significantly higher than that in the non-operative group (18.2 vs. 7.0 HU, p < 0.01). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of high-density IFF (>10 HU) to predict the need for surgical intervention were 83.9, 65.3, 75.4, 76.2, and 75.6 %, respectively.

CONCLUSIONS

High-density IFF on CT was significantly associated with the need for surgical intervention in patients with ASBO. Prospective study to validate the predictive value of high-density IFF on CT will be warranted.

Predictive Factors for Surgical Intervention in Patients over the Age of 80 with Adhensive Small-Bowel Obstruction

Adhensive small-bowel obstruction (SBO) remains a common cause of admission to surgical wards around the world. Given the growing elderly population, the number of elderly patients with adhensive SBO can be expected to increase substantially. Timely and appropriate treatment would improve morbidity and mortality rates in elderly patients with adhensive SBO. However, accurately determining which patients should undergo surgical treatment during the hospitalization remains difficult. The aim of this study was to identify predictive factors for surgical intervention in patients aged over 80 years presenting with SBO due to postoperative adhesions. A clinical and radiological data for the assessment of patients presenting with adhensive SBO were collected. A logistic regression model was applied to identify risk factors that would predict the need of surgical intervention. A total of 21 patients (13 males, 8 females) were treated during a 3.5-year period. The mean age was 85.5 ± 4.7 years, ranging from 80 to 97 years. There is no significant difference in age (group 1 87.6 ± 5.9 years vs. group 2 84.8 ± 4.3 years, p = 0.262) between two groups. Serious coexisting diseases were noted in 13 (61.9 %, 13/21) patients. Primary hypertension, cardiac diseases, and diabetes mellitus were common coexisting conditions. However, there is no significant difference in comorbidities (40 vs. 68.8 %, p = 0.325) between group 1 and group 2. Adhensive SBO was successfully treated with conservative treatment in 16 patients (76.2 %, 16/21, group 2), whereas conservative treatment failed in 5 patients (23.8 %, 5/21, group 1), who subsequently underwent laparotomy. Postoperative complication rate was 14.3 % (wound infection, 1/5) and mortality was 0 % (0/5) in group 1. One patient death was recorded in group 2 (1/16, 6.3 %). The overall mean hospital stay was 10.0 ± 5.9 days (range 3-27 days). Group 1 had a longer hospital stay than group 2. However, the difference did not reach the significant level (12.8 ± 8.2 vs. 9.1 ± 5.9 days, p = 0.274). On univariate analysis, the need for surgical intervention was significantly associated with granulocyte percentage (2.768, 0.961-7.975, p = 0.059), CT findings of free intraabdominal fluid (28.000, 1.988-394.405, p = 0.014), and level of albumin (0.265, 0.073-0.970, p = 0.045). On multivariate analysis, the predictive factor was free intraabdominal fluid (28.000, 1.988-394.405, p = 0.014). Conservative treatment remains a major consideration in patients over the age of 80. Although major cases of adhensive SBO are successfully treated with conservative methods, some fail to respond, and the independent risk factor for surgical indication is free intraabdominal fluid.

Diagnostic performance of CT findings for bowel ischemia and necrosis in closed-loop small-bowel obstruction

PURPOSE

The aim of this study was to investigate the diagnostic performance of contrast-enhanced CT (CECT) findings for bowel ischemia and necrosis in closed-loop small-bowel obstruction (CL-SBO).

MATERIALS AND METHODS

Thirty-five patients with CL-SBO confirmed by laparotomy (n = 34) or multiplanar reconstruction of thin slice CT images (n = 1) were included. Based on the surgical and clinical findings, these patients were classified into three groups: necrosis group (n = 16), ischemia without necrosis group (n = 11), and no-ischemia group (n = 8). Two blinded radiologists retrospectively reviewed CECT including multiplanar reconstruction images and evaluated 12 CT findings. The sensitivity and specificity of each finding were compared among the three groups, and logistic regression analysis was performed.

RESULTS

High attenuation of the bowel wall, intraperitoneal air, reduced enhancement of the mesenteric arteries, and small-bowel feces signs showed high specificities of 100%, 100%, 89%, and 89% but low sensitivities of 31%, 25%, 44%, and 31%, respectively, for the prediction of bowel necrosis in CL-SBO. According to multivariate logistic regression analysis, reduced bowel-wall enhancement, reduced enhancement of the mesenteric veins, and a lack of engorgement of the mesenteric veins were significant for predicting bowel ischemia or necrosis (P < 0.05).

CONCLUSIONS

Reduced enhancements of bowel wall and mesenteric veins were good indicators of bowel ischemia or necrosis. On the contrary, engorgement of the mesenteric veins was a predictor of a viable bowel.

[Intestinal obstruction, an overview]

Intestinal obstruction is a pathology commonly encountered in emergency and surgical departments. Its origin is usually mechanical, caused by obstruction of the digestive tract. It is a therapeutic emergency. Surgical treatment is required for the most severe cases.

Accuracy of abdominal auscultation for bowel obstruction

AIM: To investigate the accuracy and inter-observer variation of bowel sound assessment in patients with clinically suspected bowel obstruction.

METHODS: Bowel sounds were recorded in patients with suspected bowel obstruction using a Littmann^® Electronic Stethoscope. The recordings were processed to yield 25-s sound sequences in random order on PCs. Observers, recruited from doctors within the department, classified the sound sequences as either normal or pathological. The reference tests for bowel obstruction were intraoperative and endoscopic findings and clinical follow up. Sensitivity and specificity were calculated for each observer and compared between junior and senior doctors. Interobserver variation was measured using the Kappa statistic.

RESULTS: Bowel sound sequences from 98 patients were assessed by 53 (33 junior and 20 senior) doctors. Laparotomy was performed in 47 patients, 35 of whom had bowel obstruction. Two patients underwent colorectal stenting due to large bowel obstruction. The median sensitivity and specificity was 0.42 (range: 0.19-0.64) and 0.78 (range: 0.35-0.98), respectively. There was no significant difference in accuracy between junior and senior doctors. The median frequency with which doctors classified bowel sounds as abnormal did not differ significantly between patients with and without bowel obstruction (26% vs 23%, P = 0.08). The 53 doctors made up 1378 unique pairs and the median Kappa value was 0.29 (range: -0.15-0.66).

CONCLUSION: Accuracy and inter-observer agreement was generally low. Clinical decisions in patients with possible bowel obstruction should not be based on auscultatory assessment of bowel sounds.

Utility of RDW in Prediction of Strangulation in Emergency Setting Hernias

Most of the small bowel obstruction cases are due to adhesions and hernias. Identifying strangulated cases may save patients from consequences of unnecessary operations and save patients who need urgent intervention by early detection. Serum markers of intestinal ischemia may help to identify and detect strangulation. The aim of this study was to identify if certain blood values such as RDW can accurately predict presence of strangulation preoperatively. We reviewed files of 127 patients who were operated because of incarcerated abdominal hernias for serum biomarkers and evaluated them with the operative findings. Our results show that elevation in red cell distribution width and white blood cell count may reflect strangulation. These findings may be useful in identifying the strangulated cases that need urgent surgical intervention.

Mean Platelet Volume/Platelet Count Ratio: A New Diagnostic Parameter for Necrosis in Adhesive Small Bowel Obstruction—A Retrospective Cohort Study

Abdominal adhesions are still one of the most common causes of intestinal obstruction. A major challenge in adhesive small bowel obstruction (SBO) management is to detect ischemia as early as possible to avoid necrosis and resection. Elevated mean platelet volume and decreased platelet count have been associated with worse disease course for various ischemic diseases in many clinical studies. The objective of the current study was to evaluate the predictive value of the mean platelet volume/platelet count ratio for patients with small bowel obstruction. Data for patients with adhesive small bowel obstruction, admitted to the general surgery department of Dicle University Hospital between November 2010 and March 2014, were reviewed retrospectively. Mean platelet volume (MPV)/platelet count (PC) ratio values, demographic data, vital signs, and laboratory blood test results of the patients were analyzed. Mean platelet volume/platelet count ratio was higher in bowel necrosis group, while there were no differences between the groups in terms of mean platelet volume values. Mean platelet volume and mean platelet volume/platelet count ratio was higher in patients who underwent surgical treatment. The cutoff value with the highest sensitivity and specificity for MPV/PC ratio was 0.02855 (sensitivity 68%, specificity 65%) for predicting bowel necrosis in patients with adhesive SBO. Mean platelet volume/platelet count ratio is associated with the failure of the conservative management and the presence of bowel necrosis in patients with adhesive small bowel obstruction.

Oral gastrografin radiography for the evaluation of the functional impact of peritoneal carcinomatosis: Correlation with clinicopathological findings

This study was conducted to evaluate the functional impact of peritoneal carcinomatosis (PC) on the gastrointestinal system by oral gastrografin radiography (OGR). OGR was performed on 105 patients with PC from abdominal malignancies. The OGR characteristics were analyzed and compared with intraoperative observations. OGR provided real-time dynamic information on the functional impacts of PC. The OGR findings were normal in 9 (8.6%) and abnormal in 96 (91.4%) cases. In terms of frequency, 33 cases (31.4%) exhibited mild intestinal aggregation and flattening of the intestinal mucosa; 29 cases (27.6%) exhibited limited intestinal invasion, marginally stenotic small bowel and mucosal deformities; 26 cases (24.8%) exhibited only mild mesenteric contracture and mild slowing of gastrointestinal peristalsis; 5 cases (4.8%) exhibited obvious mesenteric contracture, ball-like changes, fixed position and disappearance of the intestinal mucosa; 2 cases (1.9%) exhibited complete pyloric obstruction; and 1 case (0.9%) exhibited duodenal obstruction. Gastric PC was associated with a higher percentage of stomach filling defects and small intestinal aggregates compared with PC from other malignancies (P<0.01 for both). In 87 cases, the ORG findings were in accordance with the intraoperative findings (κ=0.726, P<0.001), whereas 17 cases (16.2%) were underestimated and 1 (0.9%) was overestimated by OGR. This study indicated that OGR may be a useful technique for the evaluation of the functional impacts of PC on the gastrointestinal system and may help optimize the selection of patients for treatment.

Clinical Characteristics of Bowel Obstruction in Southern Iran; Results of a Single Center Experience

OBJECTIVE

To determine the epidemiological, clinical, laboratory characteristics as well as outcome of 411 patients with bowel obstruction in Southern Iran.

METHODS

This was a cross-sectional study being performed in Shahid Faghihi hospital of Shiraz between 2006 and 2012. We reviewed the medical charts of the 411 patients with initial diagnosis of bowel obstruction who were admitted to our center during the study period. The patients' demographic, clinical and laboratory findings as well as their management and outcome was recorded in data gathering forms. The data were then analyzed according to the outcome and clinical characteristics.

RESULTS

Among the 411 patients with initial diagnosis of bowel obstruction, 253 (61.5%) were men and 158 (38.5%) were women. The mean age of the patients was 48.2±19.7 years. Besides, 73.6% were observed and 26.4% were operated. Those who were operated had those who underwent operation had significantly lower frequency of obstipation (28.1% vs. 71.9%; p=0.045) and abdominal distention (32.3% vs. 67.7%; p=0.007). Intraoperative findings included adhesion band formation in 50 (48.1%), mass 18 (17.3%), and hernia 7 (6.7%). We found that the frequency of malignancy was significantly higher in those who were managed conservatively compared to those undergoing operation (64.3% vs. 35.7%; p=0.042). The mean hospital stay was significantly higher in those who underwent operation (8.1±7.5 vs. 2.6±2.2 days; p=0.035).

CONCLUSION

The results of this study demonstrates although some signs and symptoms, such as abdominal pain, vomiting, abdominal tenderness, abdominal distention, and obstipation, were more common among the patients with bowel obstruction, they were not sensitive and specific enough for definite diagnosis. Due to the lack of positive predictive value of clinical signs and symptoms in diagnosis of bowel obstruction, a reasonable and logical modality is needed for bowel obstruction diagnosis with better accuracy.

Mandatory resection of strangulation marks in small bowel obstruction?

BACKGROUND

No evidence is available on how to treat intraoperatively detected band-shaped strangulation marks of the bowel wall originating from an adhesive band or hernia ring. The authors prefer to resect these hazardous strangulation marks to avoid secondary small bowel perforation. This retrospective study investigated the prevalence of intraoperatively unrecognized ulceration and transmural necrosis at the site of the strangulation marks.

METHODS

From July 2003 to July 2011, a total of 31 of 461 patients with acute bowel obstruction underwent small bowel resection due to strangulation marks, exclusively. Seven patients had two strangulation marks, resulting in 38 strangulation marks to be analyzed.

RESULTS

From 38 examined strangulation marks, 14 (36.8 %) exhibited deep ulceration or transmural necrosis. Four (10.5 %) necrotic lesions had already been recognized intraoperatively, while 7 (18.4 %) unsuspicious strangulation marks showed deep ulceration and 3 (7.9 %) showed transmural necrosis exclusively at final histopathologic examination. The number of strangulation marks that needed to be resected for prevention of one missed deep ulceration and/or transmural necrosis of the small bowel was 3.4. The presence of deep ulceration or transmural necrosis is associated with an obvious decrease in bowel diameter caudad to the strangulation mark. No anastomotic leak occurred.

CONCLUSION

The severity of small bowel damage at the site of band-shaped strangulation marks may be underestimated by surgeons. The present series showed favorable results with a resection-per-principle policy for these strangulation marks. If an obvious decrease of bowel diameter aborally to the strangulation mark is present, resection or seromuscular invagination of the later is particularly recommended.

Geriatric small bowel obstruction: an analysis of treatment and outcomes compared with a younger cohort

BACKGROUND

Small bowel obstruction (SBO) is a common condition, but little is known about its presentation, management, and outcomes in geriatric patients.

METHODS

A retrospective review was performed comparing geriatric (≥65 years of age) and nongeriatric patients admitted with SBO. Admission characteristics, treatment, and outcomes were compared. Data analysis included Student t test and chi-square test or Fisher's exact test.

RESULTS

Among 80 geriatric and 136 nongeriatric patients, no difference was observed among admission characteristics, treatment, time to or type of surgery, length of postoperative stay, or overall complications. Cardiac complications (15% vs 0%, P = .0082) and subacute care facility discharge (29% vs 5%, P < .001) were more common for geriatric patients.

CONCLUSIONS

Compared with younger adults, elderly patients with SBO have similar presentations and overall outcomes with the exception of cardiac morbidity and discharge disposition. Preoperative attention to cardiac risk profile and discharge disposition discussion should be encouraged.

Does long intestinal tube splinting aggravate intestinal adhesions?

OBJECTIVE

Long intestinal tube splinting (LITS) is useful for clinically reducing the recurrence of adhesive small bowel obstruction (ASBO). However, a controversy exists whether LITS aggravates intestinal adhesions. This study evaluated the postoperative effects of LITS relative to simple enterolysis on intestinal adhesions in an experimental porcine model.

METHODS

A porcine model (n = 24) of dense intestinal adhesion was established by abrading the ileal wall with sterile P240 sandpaper. Enterolysis was performed on postoperative day 14. Animals were randomly divided into a group that underwent enterolysis only (control; n = 12) and those who underwent LITS as well as enterolysis (LITS; n = 12). The long intestinal tube was removed on post-LITS day 14, after abdominal radiography. All animals were euthanized on postenterolysis day 28 for assessment of intestinal adhesions using a semiquantitative macroscopic grading scale, hematoxylin-eosin histology, and hydroxyproline assay.

RESULTS

Prior to enterolysis, the experimentally induced intestinal adhesions of the two groups were similar in extent and severity. On postenterolysis day 28 the LITS and control groups were comparable with regard to adhesion loop length (p = .440), macroscopic adhesion severity (p = .820), serosal fibrosis grading (p = .450), and hydroxyproline content of the adhesion ileal segment (p = .630).

CONCLUSION

Placement of the long intestinal tube did not aggravate intestinal adhesions over that of simple enterolysis in this intestinal adhesion porcine model.

Long intestinal tube splinting really prevents recurrence of postoperative adhesive small bowel obstruction: a study of 1,071 cases

BACKGROUND

The aim of this study was to identify if long intestinal tube splinting could really decrease recurrent adhesive small bowel obstruction (ASBO) by survival analysis.

METHODS

A retrospective analysis was performed on 1,071 patients who underwent operation for postoperative ASBO between December 2001 and 2008 at our unit. According to the risk factors of recurrent ASBO, all patients were divided into high-risk recurrence group and low-risk recurrence group regardless of whether they received tube splinting. The efficiency of tube splinting for reducing recurrence in each group was investigated, respectively.

RESULTS

The risk of recurrent ASBO increased in the patients with perioperative blood loss of 300 mL or more. In the high-risk recurrence group, tube splinting can reduce recurrence (P = .045). In the low-risk recurrence group, tube splinting had no influence on recurrence (P = .91).

CONCLUSIONS

Long intestinal tube splinting can prevent recurrence of ASBO only in the patients with high risk of recurrence.

Surgical morbidity and mortality in obturator hernia: a 10-year retrospective risk factor evaluation

Obturator hernia is a rare condition occurring predominantly in elderly, thin, female patients and causes significant morbidity and mortality. Due to obscure presenting symptoms and signs, diagnosis and management are often delayed. While previous studies have attributed the high mortality to the delay in diagnosis, current literature remains controversial about this issue. The aim of this study was to identify peri-operative risk factors associated with mortality in patients with obturator hernia at our hospital.

METHODS

We retrospectively reviewed our series of 20 consecutive patients who underwent surgical repair of 21 obturator herniae and examined their clinical characteristics and post-operative outcomes.

RESULTS

Overall mortality rate was 47.6 %. Survivors did not differ from non-survivors in terms of basic demographics and operative parameters (operative time, blood loss and the need for intestinal resection). The use of computed tomography for pre-operative diagnosis was associated with reduced need for bowel resection, but did not result in shorter time to operation or improved morbidity and mortality. Our series demonstrated that early timing of surgery alone did not improve operative outcome. The absence of bowel motion and a high serum urea level at the time of operation were independent factors for mortality.

CONCLUSIONS

Obturator hernia remains a highly lethal surgical emergency. Adequate peri-operative resuscitation may be the key to further improvement in surgical outcomes.

Adult small bowel obstruction

BACKGROUND

Small bowel obstruction (SBO) is a clinical condition that is often initially diagnosed and managed in the emergency department (ED). The high rates of potential complications that are associated with an SBO make it essential for the emergency physician (EP) to make a timely and accurate diagnosis.

OBJECTIVES

The primary objective was to perform a systematic review and meta-analysis of the history, physical examination, and imaging modalities associated with the diagnosis of SBO. The secondary objectives were to identify the prevalence of SBO in prospective ED-based studies of adult abdominal pain and to apply Pauker and Kassirer's threshold approach to clinical decision-making to the diagnosis and management of SBO.

METHODS

MEDLINE, EMBASE, major emergency medicine (EM) textbooks, and the bibliographies of selected articles were scanned for studies that assessed one or more components of the history, physical examination, or diagnostic imaging modalities used for the diagnosis of SBO. The selected articles underwent a quality assessment by two of the authors using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data used to compile sensitivities and specificities were obtained from these studies and a meta-analysis was performed on those that examined the same historical component, physical examination technique, or diagnostic test. Separate information on the prevalence and management of SBO was used in conjunction with the meta-analysis findings of computed tomography (CT) to determine the test and treatment threshold.

RESULTS

The prevalence of SBO in the ED was determined to be approximately 2% of all patients who present with abdominal pain. Having a previous history of abdominal surgery, constipation, abnormal bowel sounds, and/or abdominal distention on examination were the best history and physical examination predictors of SBO. X-ray was determined to be the least useful imaging modality for the diagnosis of SBO, with a pooled positive likelihood ratio (+LR) of 1.64 (95% confidence interval [CI] = 1.07 to 2.52). On the other hand, CT and magnetic resonance imaging (MRI) were both quite accurate in diagnosing SBO with +LRs of 3.6 (5- to 10-mm slices, 95% CI = 2.3 to 5.4) and 6.77 (95% CI = 2.13 to 21.55), respectively. Although limited to only a select number of studies, the use of ultrasound (US) was determined to be superior to all other imaging modalities, with a +LR of 14.1 (95% CI = 3.57 to 55.66) and a negative likelihood ratio (-LR) of 0.13 (95% CI = 0.08 to 0.20) for formal scans and a +LR of 9.55 (95% CI = 2.16 to 42.21) and a -LR of 0.04 (95% CI = 0.01 to 0.13) for beside scans. Using the CT results of the meta-analysis for the 5- to 10-mm slice subgroup as well as information on intravenous (IV) contrast reactions and nasogastric (NG) intubation management, the pretest probability threshold for further testing was determined to be 1.5%, and the pretest probability threshold for beginning treatment was determined to be 20.7%.

CONCLUSIONS

The potentially useful aspects of the history and physical examination were limited to a history of abdominal surgery, constipation, and the clinical examination findings of abnormal bowel sounds and abdominal distention. CT, MRI, and US are all adequate imaging modalities to make the diagnosis of SBO. Bedside US, which can be performed by EPs, had very good diagnostic accuracy and has the potential to play a larger role in the ED diagnosis of SBO. More ED-focused research into this area will be necessary to bring about this change.

[Use of Gastrografin(®) in the management of adhesion intestinal obstruction]

BACKGROUND

Adhesions are the most important cause of intestinal obstruction. Approximately 25% of surgical admissions for acute abdominal conditions are due to intestinal obstruction. Better diagnostic and treatment methods of intestinal obstruction could potentially reduce mortality rate to 5-10%. Gastrografin(®) could contribute to this achieve this.

AIM

To present a protocol to treat adhesion intestinal obstruction with Gastrografin(®) that is safe, and allows shorter hospital stays and shorter time between admission and surgery.

MATERIAL AND METHODS

All patients with adhesion intestinal obstruction without symptoms of strangulation were treated with Gastrografin(®), intravenous fluids and nasogastric tube. Those in whom contrast reach the colon in 8, 12 or 24hours were considered to have partial obstruction, and were fed orally. If Gastrografin(®) failed in the following 24hours, a laparotomy was performed.

RESULTS

Out of a total of 211 episodes (164 patients), 170 episodes received contrast and in 142 cases Gastrografin(®) reached the colon (104 episodes at 8h, 11 at 12h, and 27 at 24h). A laparotomy was required in 28 patients because of failed treatment, and in another 5 for other causes.

CONCLUSIONS

A management protocol for adhesion intestinal obstruction with Gastrografin(®) is safe, reduces morbidity and mortality, and leads to a shorter hospital stay.

Early versus late adhesiolysis for adhesive-related intestinal obstruction: a nationwide analysis of inpatient outcomes

BACKGROUND

Classical teaching advocates watchful waiting for 2 days before operating on adhesive-related intestinal obstructions (AIOs). Our aim was to compare the clinical and cost outcomes of early versus late adhesiolysis for AIOs.

DESIGN

Patients undergoing adhesiolysis for AIOs from the 2007 Nationwide Inpatient Sample were stratified to early (≤2 days from admission) vs. late (>2 days) adhesiolysis. The primary outcome was in-hospital mortality and secondary outcomes were post-operative complications (POCs), post-operative length of stay (PLOS), and in-hospital cost.

RESULTS

From 5,443 patients who underwent adhesiolysis for AIOs, 53 and 47 % underwent early and late adhesiolysis, respectively. Late adhesiolysis patients were older (65.0 vs. 60.1 years) and more co-morbid compared to the early group (p < 0.05). After adjustment with propensity score methods, late adhesiolysis patients had no difference in mortality (odds ratio [OR] 0.95, 95%-confidence intervals [CI] 0.67-1.36, p = 0.79) or POCs (OR 1.01, 95%CI 0.89-1.14, p = 0.91) compared to the early group, but had 9.8 % increased PLOS and 41.9 % increased in-hospital cost (p < 0.001).

CONCLUSIONS

The 2-day limit of watchful waiting is not associated with increased mortality or POCs for those patients undergoing adhesiolysis for an AIO. Late adhesiolysis, however, was associated with significantly increased PLOS and in-hospital cost compared to early adhesiolysis.

Enhancement of a small bowel obstruction model using the gastrografin® challenge test

BACKGROUND

Based on a previous published data on small bowel obstruction (SBO), a management model for predicting the need for exploration has been adopted in our institution. In our model, patients presenting with three criteria-the history of obstipation, the presence of mesenteric edema, and the lack of small bowel fecalization on computed tomography (CT)-undergo exploration. Patients with two or less features were managed nonoperatively. An alternative tool for predicting need for operative intervention is Gastrografin (GG) challenge test.

HYPOTHESIS

We hypothesized that the GG challenge test, when used in combination with our prior model, will decrease the rate of explorations in patients not meeting the criteria for immediate operation.

METHODS

An approval from IRB was obtained to review patients admitted with a diagnosis of SBO from November 2010 to September 2011. All patients presenting with signs of ischemia, patients with all three model criteria defined previously, and those who had an abdominal operation within 6 weeks of diagnosis were excluded. All patients had an abdominal/pelvic CT and GG challenge at the time of diagnosis. Patients were compared to historic controls managed without the GG challenge (from July to December 2009). Successful GG challenge was defined as the presence of contrast in the colon after a follow-up film or a bowel movement. Data were presented as medians or percentages; significance was considered at p < 0.05.

RESULTS

One hundred and twenty-five patients with a diagnosis of small bowel obstruction were identified wherein 47 % were males. Fifty-three received a GG challenge (study), and 72 did not have a GG challenge (historic). There was no difference in age (70 vs 65 years), history of prior SBO (51 vs 49 %), history of diabetes mellitus (21 vs 18 %), history of malignancy (32 vs 39 %), or cardiac disease (30 vs 39 %). Both groups had similar number of previous abdominal operations (two vs two). The presence of mesenteric edema (68 vs 75 %), the lack of small bowel fecalization (47 vs 46 %), and a history of obstipation (25 vs 24 %) were similar in both groups. Patients in the study group had a lesser rate of abdominal exploration (25 vs 42 %, p = 0.05) and fewer complications (13 vs 31 %, p = 0.02) compared to the historic control group. There was equivalent incidence of ischemic bowel (4 vs 7 %), duration of hospital stay (4 vs 7 days), duration from admission to operation (2 vs 3 days), and mortality (8 vs 6 %); 44 patients had a successful GG challenge with nine failures. There was a greater rate of exploration in patients with a failed challenge compared to those with a successful challenge (89 vs 11 %, p < 0.01).

CONCLUSION

The use of the GG challenge enhanced the SBO prediction model by decreasing the need for exploration in patients not meeting the criteria for immediate operation. Patients who failed the GG challenge test were much more likely to undergo an exploration.

General anesthesia for intussusception reduction by enema

OBJECTIVES

Intussusception is the most frequent cause of bowel obstruction in children. Although enema is usually used as the initial treatment, surgery may be required in more than 50% of patients. General anesthesia (GA) has been suggested to increase the rate of enema success. The purpose of this study was to evaluate whether GA increases the success rate of reduction by air enema.

METHODS

In this retrospective single-center study from 1989 to the end of June 2008, patients receiving air enema for intussusception reduction were studied. Multivariable analysis using propensity score was performed to compare the success rate between patients receiving sedation or GA.

RESULTS

The success rate of air enema increased from 72% in 1989 to the current rate of 90%. When time elapsed between first symptoms and enema was >12 h, the success rate decreased significantly (Odds Ratio 0.67 [0.56-0.81], P < 0.0001). When patients were matched by propensity score, GA significantly increased the likelihood of success (OR 5.66 [2.85-12.89], P = 0.013).

CONCLUSIONS

Air enema performed under GA allows intussusception reduction in more than 90% of patients.

Utility of arterial phase of dynamic CT for detection of intestinal ischemia associated with strangulation ileus

AIM: To clarify the usefulness of arterial phase scans in contrast computed tomography (CT) imaging of strangulation ileus in order to make an early diagnosis.

METHODS: A comparative examination was carried out with respect to the CT value of the intestinal tract wall in each scanning phase, the CT value of the content in the intestinal tract, and the CT value of ascites fluid in the portal vein phase for a group in which ischemia was observed (Group I) and a group in which ischemia was not observed (Group N) based on the pathological findings or intra-surgical findings. Moreover, a comparative examination was carried out in Group I subjects for each scanning phase with respect to average differences in the CT values of the intestinal tract wall where ischemia was suspected and in the intestinal tract wall in non-ischemic areas.

RESULTS: There were 15 subjects in Group I and 30 subjects in Group N. The CT value of the intestinal tract wall was 41.8 ± 11.2 Hounsfield Unit (HU) in Group I and 69.6 ± 18.4 HU in Group N in the arterial phase, with the CT value of the ischemic bowel wall being significantly lower in Group I. In the portal vein phase, the CT value of the ischemic bowel wall was 60.6 ± 14.6 HU in Group I and 80.7 ± 17.7 HU in Group N, with the CT value of the ischemic bowel wall being significantly lower in Group I; however, no significant differences were observed in the equilibrium phase. The CT value of the solution in the intestine was 18.6 ± 9.5 HU in Group I and 10.4 ± 5.1 HU in Group N, being significantly higher in Group I. No significant differences were observed in the CT value of the accumulation of ascites fluid. The average difference in the CT values between the ischemic bowel wall and the non-ischemic bowel wall for each subject in Group I was 33.7 ± 20.1 HU in the arterial phase, being significantly larger compared to the other two phases.

CONCLUSION: This is a retrospective study using a small number of subjects; however, it suggests that there is a possibility that CT scanning in the arterial phase is useful for the early diagnosis of strangulation ileus.

How Predictive are the Signs and Symptoms of Small Bowel Obstruction

OBJECTIVE

The present study aims to determine the diagnostic significance of signs and symptoms of Small Bowel Obstruction (SBO) and to ascertain if there was any delay in presentation of the patients to the hospital.

METHODS

This retrospective case study spanning 3 years was conducted at Riyadh Medical Complex, Saudi Arabia. All adult patients admitted from the ER with a diagnosis of SBO were included in the study. The medical records of the patients with International Classification of Diseases (ICD) 9 codes 552.8, 560, 560.8, 560.81 and 560.9 were searched and retrieved.

RESULTS

A total of 195 patients were included in the study out of which 174 patients had a definitive diagnosis of SBO. The study group was composed of 76.4% males and 71.8% were aged between 20 years to 60 years. The mean duration of symptoms was 4.8 days, ranging from 6 hours to 17 days. The cardinal signs and symptoms of obstruction had low sensitivity (Range: 56-75), and specificity (Range: 28-61), but relatively high positive predictive value (PPV) (Range: 86-93). The morbidity was 13.8% while mortality was 3.4%.

CONCLUSION

The cardinal features of SBO are neither specific nor sensitive, and though they may have an acceptable PPV, the predicted rate of false positive diagnosis is unacceptable. Therefore, the clinician may not rely on the clinical picture alone for the diagnosis of SBO. The presentation of the studied patients was delayed compared to the literature and it may be an important factor in increasing morbidity and mortality, but this aspect needs to be studied further.

Stilamin for intestinal obstruction: A systematic review of efficacy

AIM: To assess the efficacy of Stilamin for intestinal obstruction.

METHODS: Cochrane Library, PubMed, Embase, SCI, CNKI, CBM, VIP and WANFANG databases were searched to identify randomized controlled trials and quasi-randomized controlled trials of Stilamin combined with conventional therapy versus conventional therapy for intestinal obstruction. The data were analyzed using the RevMan 5.1 software.

RESULTS: Thirteen studies(852 patients) were enrolled. The results of meta-analysis showed that there is a significant difference between the group of Stilamin combined with conventional therapy and the group of conventional therapy in: (1) time to relief of abdominal pain: MD = -2.96, 95% CI: (-4.08, -1.84); (2) time to relief of abdominal distention: MD = -2.98, 95% CI: (-4.33, -1.63); (3) time required for restoration of anus exhaust: MD = -4.69, 95% CI: (-5.24, -4.13); (4) rate of remission of abdominal pain and abdominal distention: according to the treatment cycle of different subgroups, there is a statistical significance among different subgroups for 48 h after treatment and at the end of treatment: RR = 1.23, 95% CI: (1.08, 1.42); RR = 1.51, 95% CI: (1.29, 1.76); (5) rate of restoration of anus exhaust: according to the treatment cycle of different subgroups, there is a statistical significance for 48 h post-treatment and at the end of the treatment: RR = 1.20, 95% CI: (1.04, 1.37), RR = 1.71, 95% CI: (1.35, 2.17); (6) mean hospitalization stay: MD = -5.09, 95% CI: (-5.95, -4.22); (7) rate of conversion to operation: RR = 0.33, 95% CI: (0.21, 0.52); and (8) amount of gastrointestinal decompression: according to the treatment cycle of different subgroups, there is a statistical significance for 48 h, 72 h post-treatment and at the end of the treatment: MD = -305.43, 95% CI: (-359.84, -251.03); MD = -345.80, 95% CI: (-406.63, -284.97); MD = -507.14, 95% CI: (-549.19, -465.09).

CONCLUSION: Current evidence suggests that Stilamin combined with conventional therapy is superior to the conventional therapy for intestinal obstruction. However, large-scale, high-quality, double-blinded RCTs are required to confirm the efficacy.

Effect of handover on the outcomes of small bowel obstruction in an acute care surgery model

BACKGROUND

An acute care surgery (ACS) model was introduced to manage emergency surgical presentations efficiently. The aim of this study was to evaluate the impact of patient handover in an ACS model on the outcomes of adhesive small bowel obstruction (SBO).

METHODS

A retrospective study was performed on patients who were admitted with adhesive SBO at Prince of Wales Hospital. The cohort consisted of all patients treated by the ACS team from its introduction in September 2005 to February 2011. Patients in the ACS cohort were divided into two groups: those whose care was handed over to another surgeon and those whose care was not. These groups of patients were compared with a random sample of 50 patients in the pre-ACS period.

RESULTS

In the ACS period, there was no significant difference in complication rates or length of hospital stay in those who were not handed over and those who were. A significantly higher proportion of operations took place during the day for the group who had been handed over (72.7% versus 36.7%; P = 0.005). There were no significant differences in complication rates or length of hospital stay in the pre-ACS and ACS period.

CONCLUSION

Management under an ACS team does not increase adverse outcomes for adhesive SBO. Patients can be safely handed over within an ACS framework. Other members of the ACS team may help facilitate continuity of care.

Recent trend of internal hernia occurrence after gastrectomy for gastric cancer

BACKGROUND

The incidence of internal hernia after gastrectomy can increase with the increasing use of laparoscopic surgery, although this trend has not been elucidated.

METHODS

Clinical information was collected from medical records and by questionnaire for 18 patients who underwent surgical treatment for internal hernia after gastrectomy for gastric cancer in 24 hospitals from January 2005 to December 2009.

RESULTS

Gastrectomy for gastric cancer was open/distal gastrectomy (DG) in five (28%) patients, open/total gastrectomy (TG) in seven (39%), laparoscopy-assisted/DG in three (17%), and laparoscopy-assisted/TG in 3 (17%). Reconstruction was by Roux-Y methods in all patients. The hernia orifice was classified as a jejunojejunostomy mesenteric defect in eight patients (44%), dorsum of the Roux limb (Petersen's space) in eight (44%), and one (5%) each of esophageal hiatus and mesenterium of the transverse colon. Among 8,983 patients who underwent gastrectomy for gastric cancer, a postoperative survey revealed that 13 patients underwent surgical treatment for internal hernia in the same hospitals. The 3-year incidence rate of the internal hernia was 0.19%, which was significantly higher after laparoscopy-assisted than open gastrectomy (0.53 vs. 0.15%, p = 0.03). Patients with an internal hernia had a mean (±SD) low weight at hernia operation (body mass index 17.9 ± 1.6 kg/m(2)) and marked weight loss after gastrectomy (weight reduction 15.6 ± 5.8%).

CONCLUSIONS

Gastrectomy with Roux-Y reconstruction for gastric cancer leaves several spaces that can cause internal hernia formation. Laparoscopic surgery and postoperative body weight loss are potential risk factors.

Laparoscopic adhesiolysis: consensus conference guidelines

AIM

Laparoscopic adhesiolysis has been demonstrated to be technically feasible in small bowel obstruction and carries advantages in terms of post-surgical course. The increasing dissemination of laparoscopic surgery in the emergency setting and the lack of concrete evidence in the literature have called for a consensus conference to draw recommendations for clinical practice.

METHODS

A literature search was used to outline the evidence, and a consensus conference was held between experts in the field. A survey of international experts added expertise to the debate. A public jury of surgeons discussed and validated the statements, and the entire process was reviewed by three external experts.

RESULTS

Recommendations concern the diagnostic evaluation, the timing of the operation, the selection of patients, the induction of the pneumoperitoneum, the removal of the cause of obstructions, the criteria for conversion, the use of adhesion-preventing agents, the need for high-technology dissection instruments and behaviour in the case of misdiagnosed hernia or the need for bowel resection.

CONCLUSION

Evidence of this kind of surgery is scanty because of the absence of randomized controlled trials. Nevertheless laparoscopic skills in emergency are widespread. The recommendations given with the consensus process might be a useful tool in the hands of surgeons.

Pathogenesis and clinical and economic consequences of postoperative ileus

Postoperative ileus is a preventable disease with surprising economic consequences. Understanding the triad of dysmotility in conjunction with an enhanced recovery program improves patient outcome, decreases length of stay in hospital, and lowers the cost. Alvimopan and other investigational promotility medications can help attain these goals. Surgeons should avoid labeling all postoperative abdominal distention as ileus, which not only prevents timely diagnosis and treatment of early postoperative small bowel obstruction or acute colonic pseudo-obstruction but also increases patient morbidity and mortality.

Decompression of the small bowel by endoscopic long-tube placement

AIM: To investigate and compare the decompression effect on small bowel obstruction of a long tube inserted using either endoscopic or fluoroscopic placement.

METHODS: Seventy-eight patients with small bowel obstruction requiring decompression were enrolled in the study and divided into two groups. Intubation of a long tube was guided by fluoroscopy in one group and by endoscopy in the other. The duration of the procedure and the success rate for each group were evaluated.

RESULTS: A statistically significant difference in the mean duration of the procedure was found between the fluoroscopic group (32.6 ± 14.6 min) and the endoscopic group (16.5 ± 7.8 min) among the cases classified as successful (P < 0.05). The success rate was significantly different between the groups: 88.6% in the fluoroscopic group and 100% in the endoscopic group (P < 0.05).

CONCLUSION: For patients with adhesive small bowel obstruction, long-tube decompression is recommended and long-tube insertion by endoscopy was superior to fluoroscopic placement.

Prospective evaluation of oral gastrografin(®) in the management of postoperative adhesive small bowel obstruction

Oral Gastrografin®, a hyperosmolar water-soluble contrast medium, may have a therapeutic effect in adhesive small bowel obstruction. However, findings are still conflicting, as some authors did not find a therapeutic advantage. So, this prospective, randomized, and clinical trial study was designed to determine the value of Gastrografin in adhesive small bowel obstruction. The primary end points were the evaluation of the operative rate reduction and shortening the hospital stay after the use of Gastrografin. A total of 84 patients were randomized into two groups: the control group received conventional treatment, whereas the study group received in addition of 100 mL Gastrografin meal. Patients were followed up within 4 days after admission, and clinical and radiological (if needed) improvements were evaluated. Although the results showed that Gastrografin can decrease the need for surgical management by 14.5 %, no statistically significant differences were observed between the two groups (P = 0.07). Nevertheless, the length of hospital stay revealed a significant reduction from 4.67 ± 1.18 days to 2.69 ± 1.02 days (P = 0.00). The use of Gastrografin in adhesive small bowel obstruction is safe and reduces the length of hospital stay. As a result, the cost of hospital bed occupancy is reduced. Hence, if there was no indication of emergency surgery, administration of oral Gastrografin as a nonoperative treatment in adhesive small bowel obstruction is also recommended.

Bowel obstruction and hernia

Bowel obstruction and abdominal hernia are commonly observed in patients seeking emergency care for abdominal pain. This article discusses bowel obstruction, adynamic ileus, acute colonic pseudo-obstruction, and abdominal hernias, with particular emphasis on the management of patients in the emergency department (ED). Although the diagnostic approach to bowel obstruction often requires imaging, abdominal hernia may be identified in most circumstances by history and physical examination alone. Urgent surgical consultation is indicated when there is a concern for bowel ischemia, strangulation, or complete obstruction. This article reviews an ED-based approach to the patient presenting with symptoms of bowel obstruction or hernia.

Small bowel obstruction: early parameters predicting the need for surgical intervention

AIM

To study and identify early clinical and radiological findings that could help to predict operative intervention for small bowel obstruction.

MATERIALS AND METHODS

One hundred and nine consecutive patients with small bowel obstruction who underwent small bowel follow-through examination with Gastrografin(®) during 2005-2006. The patients were divided into an operative group and a non-operative group, n = 44 and 65, respectively. Findings primarily noted were those which were possible to register within 1-4 h from hospital arrival.

RESULTS

In univariate analyses, factors found to be significantly associated with surgical intervention were no prior abdominal surgery, the presence of radiological differential air fluid levels, and absence of flatulence 24 h prior to admission, CRP > 10 mg/L and dehydration at admission. In multivariate analyses, the presence of dehydration and radiological differentiated air fluid levels were independent predictive factors of significance. Absence of all factors significantly favored non-operative treatment, while operative treatment was significantly favored when two or more factors were present.

CONCLUSIONS

The presence of two or more early predictive factors as defined above, available at admission, significantly correlates with a likelihood of complete obstruction and the need of surgical intervention.

Analysis of the videolaparoscopy potentiality in the surgical treatment of the bowel obstruction

CONTEXT

Laparotomy is the gold standard treatment of patients with intestinal obstruction without response to clinical management. Nowadays, literature has been demonstrating the feasibility of videolaparoscopy in the treatment of intestinal obstruction.

OBJECTIVES

To report the clinical-epidemiological profile of patients with intestinal obstruction submitted to surgery and verify the presence of contraindications for laparoscopy.

METHODS

It was done a observational, descriptive and retrospective study including adults patients with intestinal obstruction submitted to surgery at Hospital de Clínicas de Porto Alegre, RS, Brazil, between January of 2004 and October of 2008.

RESULTS

It was included 135 patients in the study, with a total of 126 patients submitted to open surgery and 9 to laparoscopy. There was similar distribution between gender and the mean age was 59 years (SD +/- 16.9). The most frequent site of obstruction was the small bowel and the most frequent etiology was adhesions. Among the patients submitted to laparotomy, 75.4% presented with abdominal distention, 68.3% previous abdominal surgery, 11.9% body mass index >30 kg/m(2), 4.8% coagulopathy and 3.2% hemodynamic instability. Among the 135 patients, only 5 of them presented with none contraindications for videolaparoscopy.

CONCLUSION

The epidemiological findings of this study are similar to the ones of the worldwide literature. Indications of videolaparoscopy in retrospective analyses have the limitation of subjective evaluation of intestinal obstruction, which was included in this study as a relative contraindication to laparoscopy.

Hyperosmolar Water-Soluble Contrast Medium in the Management of Adhesive Small-Intestine Obstruction

This prospective study investigated the value of the hyperosmolar water-soluble contrast medium Urografin® in choosing which patients with small-intestine obstruction, caused by post-operative adhesions, to treat conservatively. Thirty-seven patients with adhesive intestinal obstruction received Urografin® via a nasogastric tube. Direct abdominal radiographs were taken after 2, 4 and 8 h. Twenty-four patients (64.9%) had Urografin® in the right colon within 8 h and were considered to have partial obstruction. These patients commenced oral feeding even though abdominal radiographs revealed gas–fluid levels. In the remaining 13 patients (35.1%), Urografin® was not observed in the right colon within 8 h: three of the 13 patients (23.1%) were successfully treated conservatively; 10 of the 13 patients (76.9%) developed toxic signs and underwent surgery, with obstruction resulting from adhesive bands being confirmed at operation. Conservative treatment can be recommended for patients in whom contrast medium is observed in the right colon within 8 h following administration, regardless of the presence of obstruction signs. Absence of contrast medium in the right colon within 8 h cannot, however, be considered an indication for surgery.

Clinicoradiological score for predicting the risk of strangulated small bowel obstruction

BACKGROUND

Intestinal ischaemia as a result of small bowel obstruction (SBO) requires prompt recognition and early intervention. A clinicoradiological score was sought to predict the risk of ischaemia in patients with SBO.

METHODS

A clinico-radiological protocol for the assessment of patients presenting with SBO was used. A logistic regression model was applied to identify determinant variables and construct a clinical score that would predict ischaemia requiring resection.

RESULTS

Of 233 consecutive patients with SBO, 138 required laparotomy of whom 45 underwent intestinal resection. In multivariable analysis, six variables correlated with small bowel resection and were given one point each towards the clinical score: history of pain lasting 4 days or more, guarding, C-reactive protein level at least 75 mg/l, leucocyte count 10 x 10(9)/l or greater, free intraperitoneal fluid volume at least 500 ml on computed tomography (CT) and reduction of CT small bowel wall contrast enhancement. The risk of intestinal ischaemia was 6 per cent in patients with a score of 1 or less, whereas 21 of 29 patients with a score of 3 or more underwent small bowel resection. A positive score of 3 or more had a sensitivity of 67.7 per cent and specificity 90.8 per cent; the area under the receiver operating characteristic curve was 0.87 (95 per cent confidence interval 0.79 to 0.95).

CONCLUSION

By combining clinical, laboratory and radiological parameters, the clinical score allowed early identification of strangulated SBO.