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

Relaparotomies: Why is Mortality Higher?

BACKGROUND

Relaparotomy is sometimes required for complications that develop after abdominal surgery, but it is associated with high mortality. We aimed to investigate the independent risk factors related to mortality in patients that undergo relaparotomies.

MATERIALS AND METHODS

One hundred and fourteen patients who had relaparatomies were evaluated. Risk factors studied were patient characteristics, cause of the first operation, condition of the first operation, systemic diseases, presence of peritonitis, relaparotomy interval, cause of relaparatomy, APACHE II score, transfused blood units, number of relaparatomies, length of hospital stay, and mortality. In order to determine the independent risk factors, we carried out multivariate logistic regression analysis.

RESULTS

There were 75 male and 39 female patients with a mean age of 46.06 ± 19.98 (15-84). The most common reasons for relaparotomy were leakage from intestinal primary repair or anastomosis (29.8%). Mortality developed in 55 (48.2%) patients undergoing relaparatomy. Intestinal necrosis (p = 0038) and intraabdominal sepsis (p = 0.027) were found to be risk factors in mortality. In multivariate logistic regression analysis, advanced age (OR 0.966, p = 0. 0.017) and APACHE II score ≥ 20 (OR 0.137, p < 0.0001) were found to be independent risk factors affecting mortality.

CONCLUSION

Advanced age and APACHE II score ≥ 20 were found to be independent risk factors affecting relaparotomy-related mortality.

Systematic review of internal hernia formation following laparoscopic left nephrectomy

This is the first identifiable description where internal herniation following laparoscopic left nephrectomy necessitated gangrenous small intestinal resection; similar cases and prevention are discussed.

Long intestinal tube insertion with the ropeway method facilitated by a guidewire placed by transnasal ultrathin endoscopy for bowel obstruction

AIM

For patients with bowel obstruction, intestinal decompression by a long tube is recommended. We assessed the usefulness of a new technique for insertion of a long tube with a guidewire placed by transnasal ultrathin endoscopy.

METHODS

Nineteen patients who had been diagnosed as suffering from bowel obstruction underwent long-tube insertion with the ropeway technique using a guidewire placed by transnasal endoscopy. Thirty-three patients who had undergone conventional insertion of a long tube were included as controls. The success rate of intubation of the small bowel and the time required for the procedure were compared between the subjects and controls.

RESULTS

The success rate of intubation was 94.7% (18/19) in subjects and 84.8% (28/33) in controls (P = 0.53). The time required for insertion in the subjects and controls was 24.1 +/- 8.1 min and 48.7 +/- 25.3 min, respectively, with a statistically significant difference (P < 0.001). No complications relevant to the procedure were encountered in either of the groups.

CONCLUSION

Long-tube insertion facilitated by transnasal endoscopy reduces the time required for insertion in comparison with the conventional technique without endoscopy. Endoscopy-assisted long-tube insertion with the ropeway method is a safe and useful procedure for decompression in patients with bowel obstruction.

Second-look laparoscopy after laparoscopic relief of strangulated small bowel obstruction

Laparoscopy is increasingly used for the treatment of complex small bowel obstructions (SBO). Conventional treatment of strangulated bowel is segmental resection. We have used second-look laparoscopy to preserve bowel in 4 cases of strangulated SBO. Of the 17 patients with bowel obstruction treated laparoscopically 4 had ischemic bowel. The obstructions were relieved and second-look laparoscopy was performed 24 hours later. In 3 cases the bowel had largely regained its normal appearance; 1 case required resection based on persistent ischemia. An average of 20 cm of bowel was preserved per patient, and there were no complications in these 4 patients. In sum, we have shown second-look laparoscopy for strangulated SBO to be feasible, safe, and, in most cases, bowel conserving.

Long-tube insertion with the ropeway method facilitated by a guidewire placed by transnasal ultrathin endoscopy for bowel obstruction: a prospective, randomized, controlled trial

BACKGROUND

It is often difficult to insert a long intestinal tube in the small bowel of patients with bowel obstruction, and it often results in long procedure time and severe patient distress.

OBJECTIVE

To assess the usefulness of the ropeway method by using a guidewire placed with the assistance of transnasal ultrathin endoscopy in long-tube insertion for patients with bowel obstruction.

DESIGN

Prospective, randomized, controlled, single-center study.

PATIENTS AND INTERVENTIONS

Thirty-four consecutive patients with bowel obstruction requiring decompression participated in the study and were randomized to the insertion of a long tube with the ropeway method (ILTR) group (ie, insertion along an endoscopically placed guidewire that was passed through only the distal 4 cm of the tube) or insertion by a conventional method group (C group).

MAIN OUTCOME MEASUREMENTS

The time required for the procedure (main), success rate, x-ray exposure time, and intensity of patient distress measured with a visual analog scale of 1 to 5 (better to worse).

RESULTS

The mean (+/- standard deviation) duration of the procedure in the successful cases in the ILTR group and the C group was 16.1 +/- 5.6 minutes and 26.4 +/- 13.8 minutes, respectively (P = .010). The success rate was 100% in the ILTR group and 88% in the C group (P = .48). The mean (+/- standard deviation) x-ray exposure time and intensity of patient distress were, respectively, 16.4 +/- 8.7 minutes and 33.2 +/- 12.3 minutes (P < .001) and 2.6 +/- 0.7 and 3.7 +/- 1.2 (P = .016).

LIMITATIONS

Single-center study and small sample size to evaluate overall safety.

CONCLUSIONS

Long-tube insertion for bowel obstruction with the ropeway method facilitated by transnasal ultrathin endoscopy was superior to conventional fluoroscopic placement with regard to overall procedure success, time required, and patient comfort.

Clinical impacts of oral gastrografin follow-through in adhesive small bowel obstruction (SBO)

BACKGROUND

Many studies have shown that gastrografin can be used for diagnosis of adhesive small bowel obstruction (ASBO) and for assessing the need for surgical intervention. However, several studies have reported conflicting results. Therefore, the aim of this study is to assess the diagnostic and therapeutic effect of gastrografin in ASBO.

PATIENTS AND METHODS

Altogether, 110 patients with ASBO were randomized into control and gastrografin groups. In the gastrografin group, 100 mL of the dye was administered through a nasogastric tube. Obstruction was considered complete if the contrast failed to reach the colon on the 24-h film. Patients with gastrografin in the colon within 24 h after dye administration were considered as partially obstructed, and were submitted to nonoperative treatment. The patients were operated on if they developed signs of strangulation or failed to improve within 48 h.

RESULTS

The overall operative rate was 14.5% in gastrografin group versus 34.5% in control group, P=0.04. The time from admission to resolution of symptoms was significantly lower in gastrografin group (19.5 versus 42.6 h, P=0.001), and the length of hospital stay was shorter in gastrografin group (3.8 versus 6.9 d 0.002), and in nonoperative patients (3.1 versus 5.1 days). Sensitivity, specificity, positive predictive value, and negative predictive value for gastrografin follow-through as an indicator for operative treatment of ASBO were 87.5%, 100%, 100 % , and 97.9%, respectively.

CONCLUSIONS

Oral gastrografin helps in the management of ASBO. Oral gastrografin is safe and reduces the operative rate and time of resolution as well as hospital stay.

Abdominal compartment syndrome in patients with strangulated hernia

BACKGROUND

Intestinal obstruction (IO) leads to increased intra-abdominal pressure and abdominal compartment syndrome. The purpose of this study was to investigate the characteristics of abdominal compartment syndrome in patients with IO secondary to strangulated hernia.

METHODS

We studied 81 consecutive unselected patients presenting complicated hernias and IO. We measured intra-abdominal pressure using the intra-vesicular pressure method.

RESULTS

Preoperative (15 min) intra-abdominal pressure was higher in patients with strangulated hernias. Postoperative (15 min) intra-abdominal pressure in both groups decreased to similar values. Intra-abdominal pressure was measured during the preoperative period in patients with strangulated hernias and during the postoperative period at 15 min (13.8 +/- 6.4 mmHg), 24 h (9.8 +/- 3.2 mmHg) and 48 h (7.4 +/- 2.4 mmHg). Abdominal compartment syndrome developed in 47% cases with strangulated hernias with a mortality of five patients.

CONCLUSIONS

Serial measurements of intra-abdominal pressure evidenced the clinical severity of strangulated hernia. Intra-abdominal pressure measurement may be used as a predictor of intestinal strangulation in patients presenting acute abdominal compartment syndrome secondary to complicated hernia.

Prevalence and risk factors of mortality and morbidity after operation for adhesive postoperative small bowel obstruction

BACKGROUND

Many factors are believed to influence the mortality and morbidity after operations for adhesive small bowel obstruction (SBO).

METHODS

In a multicenter prospective cohort of 286 patients operated on for adhesive postoperative SBO, we studied the in-hospital and 30-day postdischarge mortality (early mortality) and morbidity as well as long-term mortality using univariate and multivariate analysis.

RESULTS

In the present cohort, with a median follow-up of 41 months and 9% patients lost to follow-up at the end of the study, the prevalence of early postoperative mortality was 3%. All deceased patients were over 75 years old with an American Society of Anesthesiologists (ASA) class >/=III. The prevalence of long-term mortality was 7% with the following independent risk factors: age >75 years old (hazards ratio [HR] 6.6 [95% confidence interval [CI], 2.4-18.1]), medical complications (HR 7.4 [CI, 2.2-24.3]), and a mixed mechanism of obstruction (HR 4.5 [CI, 1.5-13.7]). Prevalence of medical and surgical morbidity was 8% and 6%, respectively. Independent risk factors for medical complications were ASA class >/=III (odds ratio [OR] 16.8 [CI, 2.1-133.1]) and bands (OR 14.1 [CI, 1.8-111.5]) and for the surgical complications the number of obstructive structures >/=10 (OR 8.3 [CI, 1.6-19.7]), a nonresected intestinal wall injury (OR 5.3 [CI, 1.5-18.3]), and intestinal necrosis (OR 5.6 [CI, 1.6-19.7]). Otherwise, 3 patients with "apparent" reversible ischemia developed a postoperative intestinal necrosis followed by 2 reoperations and 1 death.

CONCLUSION

The early postoperative mortality is strongly linked with the age and the ASA class and the long-term mortality with postoperative complications. More frequent bowel resections might be suggested for patients featuring a number of obstructive structures >/=10 and an intestinal wall injury, especially when associated with a reversible intestinal ischemia.

Mechanical obstruction of the small bowel and colon

Mechanical obstruction of the small bowel and colon is moderately common, accounting for several hundred thousand admissions per year in the United States. Patients generally present with abdominal pain, nausea and emesis, abdominal distention, and progressive obstipation. Clinical findings of high fever, localized severe abdominal tenderness, rebound tenderness, severe leukocytosis, or metabolic acidosis suggest possible complications of bowel necrosis, bowel perforation, or generalized peritonitis. Differentiation of total mechanical obstruction from partial mechanical obstruction and pseudo-obstruction is important because total mechanical obstruction is generally treated surgically,whereas the other two entities are usually treated medically. Mechanical obstruction is usually suggested by plain abdominal radiographs, and confirmed by small bowel follow through,abdominal CT, or CT enteroclysis.

The incidence and morbidity of adhesions after treatment of neonates with gastroschisis and omphalocele: a 30-year review

BACKGROUND/PURPOSE

Adhesive small bowel obstruction (SBO) is a feared complication after correction of abdominal wall defects in neonates. Knowledge of its incidence and potential risk factors in a well-documented group with strict follow-up is needed to guide preventive measures.

METHODS

Records of 170 neonates with abdominal wall defects, 59 gastroschisis (GS) and 111 omphalocele (OC), were reviewed focusing on SBO. Risk of SBO was calculated, and potential risk factors were analyzed. Long-term complaints possibly associated with adhesions were assessed through questionnaire.

RESULTS

One hundred forty-seven neonates were operated on, 12 were treated nonoperatively, and 11 patients died shortly after birth. Defects were primarily closed in 128, 7 neonates needed prosthetic mesh, and 12 had a silastic sac inserted. Twenty-six (18%) neonates had SBO, 14 (25%) of 55 with GS, and 12 (13%) of 92 with OC (P = .06). Of the 26 with SBO, 26 (88%) needed laparotomy. Four patients died because of SBO. Most episodes (85%) were in the first year. Sepsis and fascia dehiscence were predicting risk factors for SBO. Abdominal pain and constipation were frequent long-term complaints not significantly associated with SBO.

CONCLUSIONS

Adhesive SBO is a frequent and serious complication in the first year after treatment of congenital abdominal wall defects. Sepsis and fascial dehiscence are predictive factors.

Small bowel obstruction secondary to an appendiceal tourniquet

BACKGROUND

An 83-year-old lady was admitted with a 3-day history of non-specific abdominal pain that had rapidly increased in severity on the day of admission necessitating an emergency laparotomy. Intra-operative findings demonstrated a mechanical small bowel obstruction secondary to a chronically inflamed appendix acting as a tourniquet around a loop of terminal ileum.

LEARNING POINT

This case highlights an extremely rare and life-threatening complication of appendicitis.

LITERATURE REVIEW

True mechanical small bowel obstruction secondary to an acutely or chronically inflamed appendix encircling the distal small bowel remains extremely rare with only ten cases reported in the literature.

CONCLUSION

Clinical assessment remains paramount in the treatment of these patients to facilitate prompt diagnosis and treatment which is vital to provide an optimal platform for post-operative recovery and survival. Although CT imaging is a highly effective investigative modality in these cases, operative treatment should not be delayed for a radiological investigation in the presence of abdominal peritonism.

Lactate and glycerol released to the intestinal lumen reflect mucosal injury and permeability changes caused by strangulation obstruction

BACKGROUND

The present study evaluates whether microdialysis of glycerol and lactate reflects mucosal injury and permeability changes after strangulation obstruction of the pig small intestine.

METHODS

Strangulation obstruction was induced by tightening a rubber band around a small bowel loop until its venous pressure increased to a level just below diastolic aortic pressure (partial strangulation), or further until cessation of flow in the main feeding artery (total strangulation). Mucosal injury and permeability of marker molecules from blood to lumen and vice versa was compared to release of glycerol and lactate to the intestinal lumen.

RESULTS

Mucosal injury, hyperpermeability, and release of glycerol were more pronounced after total than after partial strangulation. In animals with partial strangulation there was a complete restitution of the surface epithelium, and luminal glycerol and lumen-to-blood permeability of polyethylene glycol 4000 remained low. Such animals showed a sustained elevation of lactate and blood-to-lumen permeability of fluorescein isothiocyanate dextran after 2 h of partial strangulation, but a decline to baseline levels of these parameters in animals with 1 h partial strangulation.

CONCLUSION

Microdialysis of lactate and glycerol in the intestinal lumen may be used to assess structural and functional changes of the intestinal mucosa after strangulation obstruction.

Effectiveness of diagnostic paracentesis and ascites analysis for suspected strangulation obstruction

Strangulation obstruction is a surgical emergency, but its accurate diagnosis and timely surgical treatment are still matters of debate. We conducted a prospective observational study. We performed diagnostic paracentesis preoperatively for patients with suspected strangulation obstruction or, if that was impossible, we obtained ascites at the time of laparotomy. We examined each specimen to see whether ascites color and laboratory parameters could be reliable indicators of strangulation obstruction. During 18 months, 32 patients had suspected strangulation obstruction. At laparotomy, we confirmed strangulation obstruction in 21 patients, simple obstruction in two patients, and pseudo-obstruction in one patient. We treated eight patients conservatively, including one patient with a complication. We identified ascites red blood cell count, hematocrit, and lactic acid as indicators for strangulation obstruction by univariate analysis. An ascites red blood cell count was statistically high in cases with strangulation obstruction by multivariate analysis. Ascites red blood cell count above 20,000/mm(3) had a positive predictive value for strangulation obstruction of 100%, and above 40,000/mm(3), bowel resection was highly necessary. Diagnostic paracentesis and ascites analysis are useful methods for diagnosis of strangulation obstruction. Diagnostic paracentesis and ascites analysis should be combined with careful clinical exams for diagnosis of strangulation obstruction.

Early outcomes of surgery for small bowel obstruction: analysis of risk factors

OBJECTIVES

The study aimed to review the etiologies of patients who underwent surgery for small bowel obstruction (SBO) and to evaluate the risk factors affecting the early postoperative outcomes.

MATERIALS AND METHODS

A case series of 430 patients (252 men) with a mean age of 64.5 years, who underwent 437 operations for SBO, were retrospectively reviewed.

RESULTS

Peritoneal adhesions and hernia were the most common causes of SBO, contributing 42.3 and 26.8% of all cases, respectively. Strangulation occurred in 27.7% and caused nonviable bowel in 13.0% of obstructing episodes. Old age (age >/= 70 years), female patient, nonadhesive obstruction, and hernia were the independent significant factors associated with bowel strangulation. The 30-day mortality was 6.5%, and the median postoperative hospital stay was 8 days. Old age, the presence of premorbid pulmonary disease, and malignant obstruction were the independent factors associated with operative mortality. The overall complication rate was 35.5%, and old age was the only significant factor associated with postoperative complications.

CONCLUSIONS

Surgery for SBO is still associated with significant mortality and morbidity. As old age is significantly associated with an increased incidence of strangulation, operative mortality, and complications, this group of patients should be managed with extra cautions to avoid unfavorable outcome of surgery.

Adhesive postoperative small bowel obstruction: incidence and risk factors of recurrence after surgical treatment: a multicenter prospective study

OBJECTIVE

The aim of the present study was to determine the cumulative incidence and the risk factors of recurrence in patients operated on for an adhesive postoperative small bowel obstruction (SBO).

SUMMARY BACKGROUND DATA

Postoperative intraperitoneal adhesions, or bands, resulting from any type of abdominal surgery, are the main cause of adhesive postoperative small bowel obstructions, which represent a life-long issue. Recurrences after operated adhesive postoperative SBO are a threatening potentiality for patients and a difficult problem facing any surgeon. Today the cumulative incidence and the risk factors of recurrence have been retrospectively reported but have never been prospectively evaluated in a multicenter study.

METHODS

From January 1997 to January 2002, we enrolled 286 patients operated on for an adhesive postoperative SBO in a prospective multicenter trial. A systematic follow-up was carried out and ended in April 2003. Studied factors for recurrent adhesive postoperative SBO were as follows: age, gender, ASA status, number and sites of previous operations, previous operation for adhesive postoperative SBO, elapsed time from the latest operation, surgical approach, number and type of obstructive structures, site and mechanism of obstruction, final operations, and postoperative surgical and medical complications. They were analyzed using Kaplan-Meier method. A Cox regression model was used to determine the independent risk factor of recurrence.

RESULTS

The median follow-up was 41 months (range, 1-75 months). The cumulative incidence of overall recurrence was 15.9%, and for surgically managed recurrence 5.8%. In multivariate analysis, the risk factors for the overall recurrences were age <40 years (hazard ratio [HR], 2.97; confidence interval [CI], 1.48-5.94), adhesion or matted adhesion (HR, 3.79; CI, 1.84-7.78) and, for the surgically managed: adhesions or matted adhesions (HR, 3.64; CI, 1.12-11.84), and postoperative surgical complications (HR, 5.63; CI, 1.73-18.28).

CONCLUSION

Operated adhesive postoperative SBO is a clinical entity with a high recurrence rate and specific risk factors of recurrences. Thus, the patients operated on for adhesive postoperative SBO may be candidates for the preventive use of anti-adhesion agents, particularly when a risk factor of recurrence is present.

Small bowel obstruction: a population-based appraisal

BACKGROUND

Small bowel obstruction (SBO) is a common reason for surgical consultation, but little is known about the natural history of SBO. We performed a population-based analysis to evaluate SBO frequency, type of operation, and longterm outcomes.

STUDY DESIGN

Using the California Inpatient File, we identified all patients admitted in 1997 with a diagnosis of SBO. Patients were excluded if they had a diagnosis of bowel obstruction in the previous 6 years (1991 to 1996). Of the remaining cohort, the natural history of SBO over the subsequent 5 years (1998 to 2002) was analyzed. Index hospitalization outcomes (eg, surgical versus nonsurgical management, length of stay, in-hospital mortality), and longterm outcomes, including SBO readmissions and 1-year mortality, were evaluated.

RESULTS

We identified 32,583 patients with an index admission for SBO in 1997; 24% had surgery during the index admission. The distribution of surgical procedures was: 38% lysis of adhesions, 38% hernia repair, 18% small bowel resection with lysis of adhesions, and 6% small bowel resection with hernia repair. Patients who underwent operations during index admission had longer lengths of stay, lower mortality, fewer SBO readmissions, and longer time to readmission than patients treated nonsurgically. Regardless of treatment during the index admission, 81% of surviving patients had no additional SBO readmissions over the subsequent 5 years.

CONCLUSIONS

Most of the 32,583 patients requiring admission for index SBO in 1997 were treated nonsurgically, and few of these patients were readmitted. This is the first longitudinal population-based analysis of SBO evaluating surgical versus nonsurgical management and outcomes, including mortality and readmissions.

Primary tumors of jejunum and ileum as a cause of intestinal obstruction: a case control study

BACKGROUND

Small-bowel tumors are rare and account for 1-2% of all gastrointestinal neoplasms. Most of these tumors are found at surgery indicated for other diagnosis or intestinal obstruction. The rarity, unclear presentation and diagnostic difficulty of these tumors stimulated our interest to review our experience with emergency surgery for intestinal obstruction secondary to jejunoileal tumors.

METHODS

We reviewed 17 patients operated on for intestinal obstruction secondary to benign and malignant primary tumors of jejunum and ileum at our institution the last 10 years.

RESULTS

The series comprised 8 male and 9 female patients, most of them younger than 49 years of age. The most frequent tumors found were GIST (36%) followed by lymphomas (24%) and adenocarcinomas (18%). Most tumors (65%) were located in the ileum. Mean survival for patients with malignant tumors was 19.5+/-13 months, and for patients with benign tumors 72+/-20 months (p<0.05).

CONCLUSION

Jejunoileal tumors present frequently in patients younger than 49 years of age. Ileal tumors are more likely to develop intestinal obstruction than jejunal tumors. Emergency surgery for these patients precludes a complete and negative margin resection and constitutes a risk factor for residual disease and short-term survival.

Value of Water-soluble Contrast (Meglumine Amidotrizoate) in the Diagnosis and Management of Small Bowel Obstruction

INTRODUCTION

The object of the present study was to determine the effectiveness of a water-soluble contrast follow-through study for differentiating complete from incomplete small bowel obstruction (SBO) and for predicting the need for surgery.

METHODS

This prospective study was conducted at Riyadh Medical Complex, Saudi Arabia and spanned 2 years. All adult patients admitted with SBO were included, except those with obstructed hernias, peritonitis, or postabdominal irradiation. The initial resuscitation meglumine amidotrizoate (Gastrografin) follow-though was performed and was considered positive for complete obstruction if the contrast failed to reach the colon as shown on the 24-hour film. Patients were operated on only if they developed signs of strangulation or failed to improve within 48 hours.

RESULTS

Our study group consisted of 73 patients, 48 (65.7%) of whom were male. The mean age was 35.70+/-12.65 years. In 60 (82.2%) patients, contrast reached the ascending colon within 24 hours, giving a definitive diagnosis of incomplete obstruction; among these 60 cases, 49 (81.7%) resolved on conservative management. The other 13 (17.8%) patients were diagnosed as having a complete obstruction; 4 (30.8%) of them were treated conservatively, and 9 (69.2%) underwent surgery. Therefore the sensitivity, specificity, positive predictive value, and negative predictive value for meglumine amidotrizoate follow-through as an indicator for operative treatment of SBO were 45.0, 92.5, 81.7, and 69.2, respectively. The P value using Fisher's exact test was 0.0006.

CONCLUSIONS

We can confidently diagnose complete and incomplete SBO and differentiate one from the other. This accurate diagnosis indicates a high chance of success with conservative management for incomplete obstruction but does not always correlate with the need for surgical intervention.

[Value of the small bowel feces sign at CT in adhesive small bowel obstruction]

PURPOSE

The purpose of this study is to describe the CT features of the small bowel feces sign and to determine its value as a positive criteria of non-severity in adhesive small bowel obstruction.

MATERIALS AND METHODS

We performed a retrospective study of adhesive small bowel obstructions diagnosed by CT from January 2001 to December 2002. All CT examinations featuring a small bowel feces sign were included. Clinical follow-up was available for all included patients.

RESULTS

Twenty patients were included in this study. Twelve patients underwent successful conservative treatment with nasogastric aspiration. Urgent laparotomy performed in 6 cases and delayed surgical intervention performed in 3 did not show ischemic complication. Surgical management always consisted in lysis of adhesions without intestinal resection.

CONCLUSION

Recently described in the radiological literature, the small bowel feces sign appears to be the first criteria of non-severity in adhesive small bowel obstruction.

Influence of Time on Risk of Bowel Resection in Complete Small Bowel Obstruction

BACKGROUND

Little is known about the effect of passing time on risk of resection among patients with complete small bowel obstruction. We sought to provide a benchmark of the relationship of time from symptom onset to surgical treatment on the need for resection in patients with complete small bowel obstruction.

STUDY DESIGN

We performed an observational study of patients with surgically treated complete small bowel obstruction at an inner-city urban tertiary referral center and a municipal hospital. Patients were sampled randomly retrospectively (n=60), and prospectively (n=81), for a final sample of 141. Detailed clinical and time data were abstracted from medical records including out-of-hospital examinations. Risk of resection was calculated using actuarial life table methods. Linear regression was used to determine factors affecting time to treatment.

RESULTS

All patients were treated surgically for obstruction; 45% underwent resection. Resected patients had longer (11 days versus 8 days; p=0.01) and more complicated (31% versus 14% in ICU; p=0.01) hospital stays. The risk of resection was 4% among patients with 24 hours of unresponsive symptoms; it increased to 10% to 14% through 96 hours, then dropped slightly but did not disappear. Patients treated first with a tube had longer times between first examination and operation, system-time (40.6 hours versus 10.2 hours; p=0.0007), but this was not associated with an increased resection risk. System-times were shorter among patients seen first in the emergency department (median: 25.7 hours versus 59.7 hours; p=0.0001).

CONCLUSIONS

Physicians should be cautious in postponing surgery beyond 24 hours in patients with unresponsive symptoms from complete obstruction. The risk of resection rises dramatically, remains elevated through 96 hours of unresolved symptoms, then declines but does not disappear.

Postoperative short bowel syndrome

BACKGROUND

Unanticipated massive resection after intraabdominal procedures is an increasing cause of short bowel syndrome (SBS). Our aim was to determine the frequency and potential mechanisms of postoperative SBS.

STUDY DESIGN

We reviewed retrospectively the clinical course of 210 adult patients with SBS evaluated over a 20-year period.

RESULTS

Fifty-two (25%) patients had postoperative SBS. The initial operations included colectomy (n=20), hysterectomy (n=8), appendectomy (n=5), gastric bypass (n=5), and other (n=14). Intestinal obstruction (n=38) was the most common reason for resection leading to SBS, either from adhesions (n=26) or volvulus (n=12). Postoperative intestinal ischemia led to resection in 14 patients. SBS occurred from 1 day postoperatively to years later, with 16 (30%) intestinal resections occurring within 1 month. Patients undergoing resection for intestinal ischemia were more likely to undergo resection during the first month than were patients with adhesions and volvulus (86% versus 4% and 25%,respectively, p < 0.05): Patients undergoing resection for ischemia and volvulus were more likely to have remnant length<60 cm compared with those with adhesions (57% and 58% versus 23%, respectively, p < 0.05). Patients undergoing resection for adhesive obstruction were more likely to undergo multiple resections. Thirty-five (67%) patients required longterm parenteral nutrition. Seven (13%) patients died, three in the early postoperative period and four from complications of SBS.

CONCLUSIONS

SBS is a potential postoperative complication of intraabdominal procedures and accounts for a considerable proportion of tertiary referrals for SBS. Surgical treatment of postoperative obstruction after common surgical procedures is the most frequent cause. Preventing adhesions, avoiding technical errors, diagnosing a potentially ischemic intestine in a timely manner, and approaching the frozen abdomen cautiously are important strategies for preventing this condition.

Advanced abdominal imaging is not required to exclude strangulation if complete small bowel obstructions undergo prompt laparotomy

BACKGROUND

When small bowel obstruction is demonstrated clinically or radiographically to be complete, operation is advocated because of the demonstrated association of strangulation obstruction with complete obstruction and the difficulty of diagnosing strangulation obstruction. Short observation periods, fluoroscopic procedures, and cross-sectional imaging are used in treatment of partial obstruction by those who believe that observation is futile or dangerous. This approach holds that few patients resolve after a day or two of observation; if this premise were true, protracted observation should see few patients resolve and some require resection for necrotic bowel after failed observation. Observer bias and the spectrum of nonnecrotic ischemia makes end-point analysis after laparotomy difficult to interpret; few criteria or incentives exist for a surgeon to speculate that a patient brought to surgery might have recovered without it.

STUDY DESIGN

I reviewed the clinical courses of 413 obstructed patients seen over 13 years.

RESULTS

Seventy-two patients underwent immediate treatment for complete obstruction, 294 resolved without operation, and 47 patients required operation after a period of observation ranging from 3 to 15 days. All observed patients were followed using clinical examination, leukocyte count, and plain film radiography only. No bowel resections were required in patients who were observed.

CONCLUSIONS

Research opportunities exist for use of alternatives to plain film imaging in treatment of partial small bowel obstruction, but this series does not support the premise that there is a risk for bowel ischemia or bowel resection by observing patients with partial small bowel obstruction or by following them with plain films alone. Indeed, such a strategy resulted in resolution in 294 of 341 patients so treated, with readmission and reoperation rates comparable with those reported in series in which earlier operation was undertaken.

Intestinal obstruction in patients with previous laparotomy for non-malignancy

BACKGROUND

Intestinal obstruction is one of the most common surgical emergencies. The aim of this study was to identify important management information from the evaluation of patients with intestinal obstruction who had undergone previous laparotomy for non-malignancy.

METHODS

Data from 176 patients with previous laparotomy for non-malignancy, and who were operated on for intestinal obstruction, were collected and analyzed retrospectively.

RESULTS

Gastroduodenal operations, appendectomy, and obstetric/gynecologic procedures were the 3 most common previous abdominal surgeries. More than half of all bowel obstructions developed within 10 years after previous laparotomy, and particularly within the first 5 years. Most obstructions were related to adhesion, although their etiologies were diverse. The rate of bowel strangulation was much higher in patients with internal herniation, volvulus, intussusception, closed loop, and diaphragmatic hernia than in patients with simple adhesion, bezoar, tumor, and inflammation (48.3% vs 12.2%). The surgical mortality rate correlated significantly with bowel strangulation: the overall rate was 6.8%, that in patients with strangulation was 18.8%, and that in patients without strangulation was 4.2%.

CONCLUSION

The etiologies of intestinal obstruction were not only significantly related to bowel strangulation, but were also an important determinant of therapeutic strategy.

Computed tomography diagnosis of ischemia and complete obstruction in small bowel obstruction: a systematic review

This review was designed to describe the diagnostic performance of computed tomography (CT) in assessing bowel ischemia and complete obstruction in small bowel obstruction (SBO). A MEDLINE search (1966-2004) identified 15 studies dealing with the CT diagnosis of ischemia and complete obstruction in SBO. Ischemia was defined by operative findings, and complete obstruction was defined by enteroclysis or operative findings. Aggregated sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated. Eleven of 15 studies reported on the CT diagnosis of ischemia in SBO based on 743 patients. The aggregated performance characteristics of CT for ischemia in SBO were sensitivity of 83% (range, 63-100%), specificity of 92% (range, 61-100%), PPV of 79% (range, 69-100%), and NPV of 93% (range, 33.3-100%). Seven of 15 studies evaluated the CT classification of complete obstruction based on 408 patients. The aggregated performance characteristics of CT for complete obstruction were sensitivity of 92% (range, 81-100%), specificity of 93% (range, 68-100%), PPV of 91% (range, 84-100%), and NPV of 93% (range, 76-100%). This review demonstrates the high sensitivity of CT for ischemia in the setting of SBO and suggests that a CT scan finding of partial SBO is likely to reflect a clinical condition that will resolve without surgical intervention.

Does serum hexosaminidase activity play a role in the diagnosis of strangulated bowel obstruction? An experimental study

Strangulation is associated with an increased risk of mortality and morbidity in patients with mechanical bowel obstruction. The accurate and early recognition of the presence of strangulation is important to allow safe nonoperative treatment. A number of studies have shown that there was no single and reliable test to detect or exclude the presence of strangulation. The aim of this study was to evaluate the role of serum hexosaminidase (Hex) levels in recognition of strangulation in an experimental model of closed loop small bowel obstruction. Forty-two Wistar albino rats were divided into four groups: I, control (n = 5); II, sham laparotomy (n = 5); III, simple obstruction (n = 16); and IV, strangulation groups (n = 16). Activity levels of total Hex and its fractions (Hex A and B) were assayed in serum samples obtained from rats after 3 and 8 hr. Samples of small bowel were also evaluated histologically. Histological evaluation of bowel sections obtained from the strangulation group after 8 hr, revealed transmural hemorrhagic infarction in all animals with a mean +/- SD total Hex activity of 978.25 +/- 150 nmol/hr/ml, which was significantly higher than that in the other groups (P < 0.001). Although sections of bowel from the strangulation group after 3 hr showed severe ischemic injury, the activities of total Hex, Hex A, and Hex B were not different from those of the control, sham, and simple obstruction groups. Histological examination of these groups did not show any sign of ischemia. Total Hex, Hex A, and Hex B activities in the strangulation group were all significantly greater than the activities seen in the simple obstruction group (P < 0.001, for all). In conclusion, increased serum hex levels indicate irreversible transmural infarction only in the late period of strangulation in the closed loop small bowel obstruction model. It seems unuseful for detecting reversible and/or irreversible ischemia in the early period of strangulation.

Fluid resuscitation improves intestinal blood flow and reduces the mucosal damage associated with strangulation obstruction in pigs

BACKGROUND

Strangulation obstruction of the small bowel is associated with local and systemic circulatory changes, local loss of fluid, and damage of the strangulated bowel segment. We wanted to examine to which extent these changes can be prevented by intravenous fluid administration.

MATERIALS AND METHODS

In anesthetized pigs, strangulation obstruction was induced by increasing the pressure in a baby pressure gasket placed around a loop of ileum until venous pressure in the loop reached 50 mm Hg. During the strangulation period (180 min), a group of eight animals (Fluid(min) group) received 10 ml. kg(-1). hour(-1) Ringer acetate solution intravenously, whereas another eight animals (Fluid(max) group) received 55 ml. kg(-1). hour(-1) Ringer acetate solution intravenously. Blood flow to the strangulated bowel was measured by transit time flowmetry and colored microspheres. After completed experiments, whole wall samples of the strangulated loop were selected for microscopy.

RESULTS

In the Fluid(min) group, the heart rate increased, the arterial pressure decreased markedly, and the urine output decreased toward zero. In the Fluid(max) group, the heart rate and arterial pressure remained fairly constant and the urine output increased. Blood flow to the strangulated bowel decreased in both groups, but significantly more in the Fluid(min) group. The intestinal blood flow was highly dependent on the arterial blood pressure. The strangulated mucosa showed markedly more damage in the Fluid(min) group than the Fluid(max) group. The degree of mucosal damage correlated linearly with the mucosal blood flow.

CONCLUSION

The administration of large amounts of fluid to animals with strangulation obstruction normalized the arterial pressure and improved the intestinal blood flow thus minimizing damage to the intestinal mucosa.

Use of morphology to characterize and manage common adnexal masses

The use of grey-scale ultrasound morphology to characterize a pelvic mass may also be called 'pattern recognition'. The grey-scale ultrasound image provides us with the same information as that obtained by the surgeon or pathologist when he or she cuts a surgical specimen to see what it looks like inside. Many pelvic masses have such a typical macroscopic appearance that a fairly confident diagnosis can be made on the basis of their macroscopic appearance alone, i.e. on the basis of their grey-scale ultrasound image. This is true of most dermoid cysts, endometriomas, corpus luteum cysts, hydrosalpinges and peritoneal pseudocysts, and of many paraovarian cysts and benign solid ovarian tumours, for example, fibromas, fibrothecomas, thecofibromas, thecomas and Brenner tumours. A mass with irregularities should always evoke suspicion of malignancy. A mass that is completely smooth is almost certainly benign. Papillary projections--considered a strong sign of malignancy--are more common in borderline tumours than in invasive cancers but may also be seen in benign tumours, for example, in adenofibromas. They explain many false-positive ultrasound diagnoses of malignancy. Pattern recognition is superior to all other ultrasound methods (e.g. simple classification systems, scoring systems, mathematical models for calculating the risk of malignancy) for discrimination between benign and malignant extrauterine pelvic masses. Today's often too liberal use of transvaginal ultrasound gives clinicians problems. Many adnexal masses that probably would have remained undetected before the ultrasound era are now found incidentally at transvaginal ultrasound examination in women without symptoms of an adnexal tumour. The natural history of incidentally detected pelvic masses with benign ultrasound morphology is not known. Therefore, the optimal management of such tumours is also unknown.

Clinical Studies of Strangulating Small Bowel Obstruction

Reliable preoperative diagnosis of intestinal necrosis in strangulating small bowel obstruction (SSBO) is difficult, and, as yet, no reliable marker has been described. We, therefore, retrospectively examined clinical symptoms and hematobiochemical data of patients with SSBO in our surgical wards. Thirty-seven patients with SSBO were analyzed in this study. They were divided into two groups: group A (13 patients), the presence of gangrenous intestine; and group B (24 patients), the absence of it. By means of χ2 test, Student t test, or Welch t test, peritoneal signs, white blood cell count (leukocytosis or leukopenia), systemic inflammatory response syndrome (SIRS), shock, and base deficit were significantly associated with whether gangrenous intestine existed or not. Next, in simple regression analysis, base deficit was significantly correlated with the length of gangrenous intestine. In stepwise logistic regression analysis, SIRS was independently correlated with the presence of gangrenous intestine. If SIRS or metabolic acidosis is seen in patients with SSBO, the intestine is certainly gangrenous

Delay in operative treatment among patients with small bowel obstruction

BACKGROUND AND AIMS

Delay in operative treatment for small bowel obstruction (SBO) has been shown to affect outcome adversely. The objective of this study was to detect time trends in treatment delay for patients with SBO during the study period 1961 to 1995 and to investigate factors influencing and factors affected by delay.

MATERIALS AND METHODS

The records of 815 patients with 921 operations for SBO from 1961-1995 were studied. Patients with large bowel obstruction, paralytic ileus and SBO caused by abdominal cancer or intussusception were excluded. Data were analysed with descriptive statistics and multiple linear regression analyses.

RESULTS

Old age and female sex were associated with increased treatment delay. Delay in hospital increased from 5 hours (median) in the 1960'ies to 16 hours (median) in the 1990'ies. Treatment delay correlated significantly with postoperative morbidity and hospital stay. Mortality increased after prolonged treatment delay in SBO caused by hernias whereas no significant increase in mortality was observed among adhesive obstructions.

CONCLUSIONS

Hospital delay increased throughout the study period. Old patients and women had a longer median treatment delay than did young ones and men. Treatment delay led to an increase in postoperative morbidity and hospital stay after surgery for SBO.

Randomized clinical study of Gastrografin administration in patients with adhesive small bowel obstruction

BACKGROUND

Oral Gastrografin has been used to differentiate partial from complete small bowel obstruction (SBO). It may have a therapeutic effect and predict the need for early surgery in adhesive SBO. The aim of this study was to determine whether contrast examination in the management of SBO allows an early oral intake and reduces hospital stay.

METHODS

Eighty-three patients admitted between February 2000 and November 2001 with 90 episodes of symptoms and signs suggestive of postoperative adhesive SBO were randomized into two groups, a control group and Gastrografin group. Patients in the control group were treated conservatively. If symptoms of strangulation developed or the obstruction did not resolve spontaneously after 4-5 days, a laparotomy was performed. Patients in the Gastrografin group received 100 ml Gastrografin. Those in whom the contrast medium reached the colon in 24 h were considered to have partial SBO, and were fed orally. If Gastrografin failed to reach the colon and the patient did not improve in the following 24 h a laparotomy was performed.

RESULTS

Conservative treatment was successful in 77 episodes (85.6 per cent) and 13 (14.4 per cent) required operation. Among patients treated conservatively, hospital stay was shorter in the Gastrografin group (P < 0.001). All patients in whom contrast medium reached the colon tolerated an early oral diet. Gastrografin did not reduce the need for operation (P = 1.000). No patient died in either group.

CONCLUSION

Oral Gastrografin helps in the management of patients with adhesive SBO and allows a shorter hospital stay.

Small Bowel Obstruction

The optimal treatment of patients with small bowel obstruction should be predicated upon answering the following diagnostic questions in each patient: 1) does the patient have mechanical bowel obstruction or an ileus?, 2) could the patient have colonic obstruction or a cause of obstruction other than adhesions (eg, hernia, cancer, Crohn's disease)?, 3) is the obstruction partial or complete?, and 4) is strangulation present, and hence immediate operation necessary, or is a period of observation appropriate? The most efficient way to answer these questions in many patients is by performing a careful history and physical examination, laboratory tests, and CT scanning. Surgical intervention should occur within 48 hours of admission in the vast majority of patients with complete small bowel obstruction due to adhesions. The chance for durable endoscopic treatment of any patient with SBO, in our opinion, is remote.

Operative Acute Small Bowel Obstruction: Admitting Service Impacts Outcome

Early surgical intervention in acute small bowel obstruction (SBO) has long been recognized as an important factor in preventing morbidity and mortality. Factors associated with surgically managed acute SBO were analyzed for delay in intervention and impact on outcome. A retrospective review of all patients evaluated for SBO on the surgical teaching service of the Greenville Hospital System from July 1, 1997 to June 30, 2000 was performed. Data were collected on patient demographics, admission information (date, admitting service, physical examination, and laboratory values), comorbidity, diagnostic studies, surgery date, operative findings, postoperative complications, operative mortality, and discharge date. Analysis of the data revealed 157 cases of presumed SBO of which 61 were managed nonoperatively and 96 required surgery. Acute SBO was diagnosed in 65 patients who constitute the basis for this review. Of these 65 patients 43 (66%) were admitted to the surgical service, 25 (38%) required small bowel resection, and 17 (26%) developed morbidity and/or mortality. When analyzed for morbidity and mortality the only characteristics that were statistically significant were the admitting service ( P = 0.003) and length of stay ( P = 0.003). On further analysis of admitting service and patient outcomes several factors were significant when we compared medical service admissions to surgical service admissions. These included days from admission to surgery ( P = 0.003), length of stay ( P = 0.019), morbidity ( P = 0.004), mortality ( P = 0.005), and combined morbidity and mortality ( P = 0.003). Mortality of patients admitted to the medical service was 27 per cent compared with 2 per cent for the surgical service. There were no differences in morbidity and mortality when analyzed by the need for small bowel resection, patient age, etiology of obstruction, or presence of comorbidities. None of the factors studied were useful in predicting the need for small bowel resection. Our findings agree with those of previous investigators with regard to 1) lack of association between the preoperative evaluation and the need for small bowel resection and 2) the association between delay in diagnosis and increased morbidity and mortality. In addition we have found that one of the primary causes of delay in treatment for SBO was admission to the medical service. This delay led to significantly higher mortality in these patients. We recommend early surgical evaluation for any patient admitted with SBO as a differential diagnosis.