Determination of therapeutic strategy for adhesive small bowel obstruction using water-soluble contrast agents: An audit of 776 cases in a single center

A systematic review of participant descriptors reported in studies of adhesive small bowel obstruction

AIM

Reporting of participant descriptors in studies of adhesive small bowel obstruction (ASBO) can help identify characteristics associated with favourable outcomes and allow comparison with other studies and real-world clinical populations. The aim was to identify the pattern of participant descriptors reported in studies assessing interventions for ASBO.

METHOD

This systematic review was registered with PROSPERO (CRD42021281031) and reported in line with the PRISMA checklist. Systematic searches of Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were undertaken to identify studies assessing operative and non-operative interventions for adults with ASBO. Studies were dual screened for inclusion. Descriptors were categorised into conceptual domains by the research team.

RESULTS

Searches identified 2648 studies, of which 73 were included. A total of 156 unique descriptors were identified. On average, studies reported 12 descriptors. The most frequently reported descriptors were sex, age, SBO aetiology, history of abdominal surgery, BMI and ASA classification. The highest number of descriptors in a single study was 34, compared to the lowest number of descriptors which was one. Pathway factors were the least frequently described domain. Overall, 37 descriptors were reported in just one study.

CONCLUSION

There is a lack of consistency in participant descriptors reported in studies of SBO. Furthermore, a significant proportion of the descriptors were used infrequently. This makes it challenging to assess whether study participants are representative of the wider population. Further work is required to develop a Core Descriptor Set to standardise the reporting of patient characteristics and reduce heterogeneity between studies.

Feasibility of Gastrografin Use for Adhesive Small Bowel Obstruction in Low-Income Countries

INTRODUCTION

Small bowel obstruction (SBO) is one of the most common causes for hospital admission in Ethiopia. The use of water-soluble contrast agents (WSCAs) such as Gastrografin to manage adhesive SBO can predict nonoperative resolution of SBO and reduce decision time to surgery and length of hospital stay. However, nothing is known about practice patterns and Gastrografin use in low-income settings. We sought to characterize current management practices, including use of WSCAs, as well as outcomes for patients with SBO in Addis Ababa, Ethiopia.

METHODS

We conducted a mixed-methods study consisting of a survey of surgeons throughout Ethiopia and a retrospective record review at five public, tertiary care-level teaching hospitals in Addis Ababa.

RESULTS

Of the 76 surgeons who completed the survey, 63% had heard of the use of WSCAs for SBO and only 11% used oral agents for its management. Chart review of 149 patients admitted with SBO showed the most common etiology was adhesion (39.6% of admissions), followed by small bowel volvulus (20.8%). Most patients (83.2%) underwent surgery during their admission. The most common diagnosis in patients who did not require surgery was also adhesion (68.0%), as well as for those who had surgery (33.9%), followed by small bowel volvulus (24.2%).

CONCLUSIONS

The etiology of SBO in Ethiopia may be changing, with postoperative adhesions becoming more common than other historically more prevalent causes. Although a Gastrografin protocol as a diagnostic and potentially therapeutic aid for SBO is feasible in this population and setting, challenges can be anticipated, and future studies of protocol implementation and effectiveness are needed to further inform its utility in Ethiopia and other low-income and middle-income countries.

Obstrucción intestinal por adherencias: un lienzo en blanco en el que el cirujano elige los colores

Introducción. La obstrucción intestinal es una patología de alta prevalencia. Su abordaje diagnóstico y terapéutico ha evolucionado acorde con el avance del conocimiento e implementación de la tecnología. El impacto de sus complicaciones obliga a redoblar esfuerzos en pro de lograr una mayor efectividad. Se hizo una aproximación reflexiva al problema, mediante una identificación de los puntos controversiales de interés para el cirujano general. Métodos. Se realizó una búsqueda sistemática de la literatura en varias bases de datos, utilizando dos ecuaciones de búsqueda que emplearon términos seleccionados a partir de los tesauros “Medical Subject Heading” (MeSH) y “Descriptores en Ciencias de la Salud” (DeCS). Resultados. Se recolectaron 43 artículos y a partir de ellos se construyó el texto de revisión. La identificación pronta de los posibles candidatos a cirugía, mediante un esquema diagnóstico y terapéutico, se constituye en una prioridad en el manejo de estos pacientes. De igual manera, se efectúan consideraciones en la toma de decisiones con respecto a la vía quirúrgica, así como recomendaciones técnicas operatorias producto de la experiencia y lo reportado en la literatura. Existen factores propios del cirujano, del contexto y del paciente, que inciden en la resolución del problema. Conclusión. La obstrucción intestinal y sus implicaciones clínicas obligan a una reevaluación constante de su estado del arte y avances en el manejo, tendiente a una búsqueda de oportunidades para impactar favorablemente en su curso clínico. Hay estrategias por implementar, inclusive el manejo laparoscópico en casos seleccionados.

RISK FACTORS FOR REOPERATION, MORBIDITY, AND MORTALITY IN PATIENTS WITH SMALL BOWEL OBSTRUCTION SUBMITTED TO SURGICAL TREATMENT

ABSTRACT - BACKGROUND: Small bowel obstruction (SBO) is a frequent cause of emergency department admissions. AIM: This study aimed to determine risk factors of reoperations, postoperative adverse event, and operative mortality (OM) in patients surgically treated for SBO. METHODS: This is a retrospective study conducted between 2014 and 2017. Exclusion criteria include gastric outlet obstruction, large bowel obstruction, and incomplete clinical record. STATA version 14 was used for statistical analysis, with p-value <0.05 with 95% confidence interval considered statistically significant. RESULTS: A total of 218 patients were included, in which 61.9% were women. Notably, 88.5% of patients had previous abdominal surgery. Intestinal resection was needed in 28.4% of patients. Postoperative adverse event was present in 28.4%, reoperation was needed in 9.2% of cases, and a 90-day surgical mortality was 5.9%. Multivariate analysis determined that intestinal resection, >3 days in intensive care unit (ICU), >7 days with nasogastric tube (NGT), pain after postoperative day 3, POAE, and surgical POAE were the risk factors for reoperations, while age, C-reactive protein, intestinal resection, >3 days in ICU, and >7 days with NGT were the risk factors for POAE. OM was determined by >5 days with NGT and POAE. CONCLUSIONS: Postoperative course is determined mainly for patient’s age, preoperative level of C-reactive protein, necessity of intestinal resection, clinical postoperative variables, and the presence of POAE.

Diagnosis and management of small bowel obstruction in virgin abdomen: a WSES position paper

Background

Small bowel obstruction (SBO) is a common surgical emergency, causing high morbidity and healthcare costs. The majority of SBOs are caused by adhesions that result from previous surgeries. Bowel obstruction, however, also occurs in patients without previous operation or known pathology, a so called virgin abdomen. It is unknown if small bowel obstruction in the virgin abdomen (SBO-VA) can be managed according to the same principles as other cases of small bowel obstruction. The aim of this position paper is to evaluate the available evidence on etiology and management of small bowel obstruction in the virgin abdomen.

Methods

This is a narrative review with scoping aspects. Clinical topics covered in this review include epidemiology and etiology of SBO-VA, diagnosis and imaging, initial assessment, the role of surgical management in SBO-VA, and the role of non-operative management in SBO-VA.

Results

Our scoping search revealed seven original studies reporting original patient data related to SBO-VA. All the included studies are retrospective cohorts, with populations ranging between 44 and 103 patients with SBO-VA. Adhesions were found to be the cause of the obstruction in approximately half of the reported cases of SBO-VA. A relatively high number of cases of SBO-VA were managed surgically with studies reporting 39–83%. However, in cases where a trial of non-operative management was started, this was generally successful.

Conclusion

The data available suggest that etiology and treatment results for patients with SBO-VA are largely comparable to the results in patients with SBO after previous abdominal surgery. We therefore propose that patients with a virgin abdomen could be treated according to existing guidelines for SBO and adhesive small bowel obstruction.

Use of the Water-Soluble Contrast Medium Gastrografin in Treatment of Adhesive Small Bowel Obstruction in Patients with and Without Chronic Radiation Enteropathy: A Single-Center Retrospective Study

Background

This retrospective cohort study from a single center aimed to compare patient outcomes following the use of the water-soluble contrast medium Gastrografin in the treatment of adhesive small bowel obstruction (ASBO) in patients with and without a history of chronic radiation enteropathy (CRE).

Material/Methods

Fifty-nine patients with CRE-induced small bowel obstruction (SBO) and 53 patients with ASBO at Jinling Hospital between April 2014 and February 2018 were enrolled. The patients were given 100 ml Gastrografin through a naso-jejunal tube, and erect abdominal X-rays were taken. Risk factors were found to be correlated with successful non-operative management (SNM) through statistical analyses.

Results

The success rate of conservative treatment was higher in the Gastrografin group than in the control group (P<0.05). The Gastrografin challenge test is predictive of need for surgery in CRE-induced SBO and ASBO (AUC=0.860 and 0.749, respectively). The predictors associated with SNM in the CRE-induced SBO group were the total dose of radiotherapy, the Gastrografin challenge test, and previous operations for SBO. In the ASBO group, the predictors were the Gastrografin challenge test and previous operations for SBO. The operation rate of SBO patients with Gastrografin treatment was significantly lower than that in the control group (P<0.05).

Conclusions

The findings from this study showed that the use of Gastrografin effectively resolved ASBO in patients with and without a history of CRE, but a long-term requirement for surgery could not be avoided. The Gastrografin challenge may be a useful test to predict surgical outcomes.

Short-Term Clinical Outcomes after Using Novel Deeper Intubation Technique (DIT) of Ileus Tube for Acute Bowel Obstruction Patients

Background

The ileus tube has been widely used for the treatment of acute small bowel obstruction. However, it is difficult to get the tube sufficiently adjacent to the obstruction site due to various reasons.

Methods

We developed a novel intubation technique, named Deeper Intubation Technique (DIT), by using the Zebra Urological Guidewire and digital gastrointestinal fluoroscopy, where we deepened the catheter intubation, and further compared the effects of DIT with the Traditional Intubation Technique (TIT) on the short-term clinical outcomes of 183 patients.

Results

The average intubation depth of DIT apparently exceeds that of TIT (213.89 ± 31.11 vs. 134.67 ± 18.22 cm, P < 0.001). Compared with patients in the TIT group, patients in the DIT group got a lower pain score (P < 0.001), shorter recovery time for anal exhaust defecation (2.87 ± 1.50 vs. 3.37 ± 1.52 d, P = 0.040), higher recovery rate in anal exhaust defecation (24 h, 16.8% vs. 5.7%, P = 0.021; 48 h, 46.3% vs. 27.3%, P = 0.009), better symptomatic remission rate and imaging relief rate (P < 0.05), and increased drainage volume (1006.88 ± 583.45 vs. 821.02 ± 358.73 ml, P = 0.009). Importantly, the emergency surgery rate in the DIT group was lower than that in the TIT group (3.2% vs. 13.6%, P = 0.014). In addition, the DIT procedure was effective for patients with adhesive obstruction but not for cancerous and stercoral bowel obstruction.

Conclusion

Compared to TIT, DIT produced better short-term clinical outcomes, indicating that DIT is a safe and feasible technique for the treatment of adhesive intestinal obstruction.

Etiologies and outcomes of emergency surgery for acute abdominal pain: an audit of 1456 cases in a single center

PURPOSE

There are few studies that have reported the details of emergency surgery for acute abdominal pain. This study aimed to clarify the etiologies and outcomes of emergency abdominal surgery among patients in different age categories.

METHODS

Between January 2014 and December 2016, 1456 patients aged 7 years or older who underwent emergency surgery for acute abdominal pain at our institution were enrolled in this study. The patients were divided into three age groups: 7-17 years (n = 146), 18-64 years (n = 628), and 65 years or older (n = 682). The clinical characteristics, etiology of abdominal emergency surgery, and surgical outcomes were compared among the three groups.

RESULTS

The proportion of patients with comorbid conditions significantly increased with increasing ages. In patients in between 7 and 17 and in those between 18 and 64 years, acute appendicitis was the most frequent etiology, followed by bowel obstruction. Conversely, the most frequent etiology was bowel obstruction, followed by biliary disease in patients 65 years or older. The morbidity and mortality rate were 12% and 0.2% in patients 18-64 years, and 25% and 1.8% in patients 65 years or older (P < 0.001 and P = 0.004, respectively). In the group of patients 65 years or older, more patients were transferred to different hospitals for rehabilitation or recovery.

CONCLUSIONS

This study demonstrated significant differences among patients in different age categories in terms of the etiologies and outcomes of emergency abdominal surgery.

Clinical Effect of Water-Soluble Contrast Agents for Small Bowel Obstruction in the Virgin Abdomen

BACKGROUND

Several studies have investigated the diagnostic and therapeutic role of water-soluble contrast agents (WSCAs) in adhesive small bowel obstruction (SBO). However, the clinical effect of WSCA for SBO without previous intraabdominal operation (i.e., virgin abdomen, VA) is unclear. The aim of this study was to clarify the clinical effect of WSCA for SBO in the VA.

METHODS

Between January 2008 and December 2015, 838 consecutive patients with SBO were initially managed with WSCA and were included in the study. Abdominal X-rays were taken 5 h after administration of 100 ml WSCA and classified into complete/incomplete obstruction groups. The medical records of the patients with SBO were retrospectively analyzed and divided into two groups of patients with VA or non-VA.

RESULTS

A total of 44 and 794 VA and non-VA patients were identified, respectively. Six VA patients (13%) and 121 non-VA patients (15%) were classified with complete obstruction (p = 1.000) and subjected to operative exploration on the same day. There were no significant differences in the duration of nasogastric tube decompression (2.2 versus 2.5 days, p = 0.400) and intervals until the initiation of oral intake (2.4 versus 2.6 days, p = 0.553) between the VA and non-VA groups. The overall operative rate was 16% in the VA and 17% in the non-VA groups (p = 1.000). Compared with non-VA, VA was associated with shorter hospital stays (9.6 versus 11.3 days, p = 0.006).

CONCLUSIONS

WSCA for SBO in the VA is as effective as in non-VA patients in terms of a therapeutic strategy.