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Falola AF, Dada OS, Ndong A, Akande DG. Etiology and management outcomes of adult mechanical bowel obstruction in Nigeria: A systematic review and meta-analysis. World J Surg 2024; 48:29-39. [PMID: 38686745 DOI: 10.1002/wjs.12017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/16/2023] [Indexed: 05/02/2024]
Abstract
BACKGROUND Adult mechanical bowel obstruction (AMBO) has been previously reported to be majorly caused by hernias in developing countries. In Nigeria, however, there has been a recent change in pattern with adhesions now being the leading cause. The aim of this systematic review is to examine the changing pattern of the causes, and outcomes of patients managed for AMBO in Nigeria. METHODS Relevant keywords relating to AMBO were used to conduct a search on PubMed, Web of Science, Google Scholar, and AJOL. The search returned 507 articles, which were subjected to title, abstract, and full text screenings, according to the inclusion and exclusion criteria. This generated 10 articles which were included in the final qualitative synthesis. RESULTS The total sample size across the 10 studies was 1033. Adhesions, hernias, and intra-abdominal tumors, responsible for 46.25%, 26.31%, and 12.23% of cases respectively, were the major causes of AMBO in Nigeria. 65.6% of cases were managed operatively and 34.4% were managed conservatively. The meta-analysis revealed high morbidity and mortality rates of 31% (95% CI: 17; 44, 5) and 11% (95% CI: 6; 15, 5), respectively, among adult patients managed for mechanical bowel obstruction in Nigeria. CONCLUSIONS Adhesion, which results predominantly from appendicectomy is the most common cause of AMBO in Nigeria. This is unlike former reports where hernia was the most common cause. Morbidity results majorly from wound infection, recurrent adhesions, and postoperative enterocutaneous fistula. The mortality rate is similar to reports from various West African studies, and it is significantly influenced by surgical intervention time.
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Affiliation(s)
- Adebayo Feranmi Falola
- University of Ibadan College of Medicine, Ibadan, Nigeria
- Department of General Surgery, Surgery Interest Group of Africa (SIGAf), Lagos, Nigeria
| | - Oluwasina Samuel Dada
- Department of General Surgery, Surgery Interest Group of Africa (SIGAf), Lagos, Nigeria
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Abdourahmane Ndong
- Department of General Surgery, Surgery Interest Group of Africa (SIGAf), Lagos, Nigeria
- Department of Surgery, Gaston Berger University, Saint-Louis, Senegal
| | - Damilola Grace Akande
- University of Ibadan College of Medicine, Ibadan, Nigeria
- Department of General Surgery, Surgery Interest Group of Africa (SIGAf), Lagos, Nigeria
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Ghabisha S, Ahmed F, Altam A, Hassan F, Badheeb M. Small Bowel Obstruction in Virgin Abdomen: Predictors of Surgical Intervention Need in Resource-Limited Setting. J Multidiscip Healthc 2023; 16:4003-4014. [PMID: 38107087 PMCID: PMC10725698 DOI: 10.2147/jmdh.s441958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023] Open
Abstract
Background Limited evidence is available regarding the management of small bowel obstruction in the virgin abdomen (SBO-VA), with most studies excluding this entity. This study aims to assess the available data on the treatment outcomes and predictors of surgical intervention in SBO-VA. Methods A retrospective cross-sectional study was conducted between 2015 and 2021, including all diagnosed and managed cases of SBO-VA at Al-Nasar Hospital. Patients were divided according to the treatment approach into surgical or conservative groups. Preoperative laboratory and radiologic data were gathered and compared between groups. Results During the study period, 67 cases, primarily males (58.2%), with an average age of 52.2±14.4 years were assessed. Common comorbidities included diabetes (20.9%) and hypertension (16.4%). Key symptoms were rebound tenderness (82.1%) and abdominal tenderness (70.1%). The predominant etiology was adhesions (23.9%). About 46.2% received conservative treatment, 53.8% underwent urgent surgery. Conservative treatment failed in 9.4% of cases, and complications arose in 23.9%, with most being fever (17.9%). Factors necessitating surgical management included older age (58.8 ±11.7 vs 44.9 ±13.8 years, p<0.001), previous hospital admission (p<0.001), presence of abdominal tenderness (p=0.030), longer abdominal pain duration (4.0 ±0.9 vs 2.1 ±0.6 days, p<0.001), higher C- reactive protein (p= 0.033), higher white blood cell (p= 0.006), longer time to hospital presentation (75.3 ±17.2 vs 39.0 ±22.8 days, p= <0.001), small bowel thickness ≥3 cm (p=0.009), and reduced bowel enhancement (p <0.001) on computed tomography imaging. In surgical group, the need for ICU admission was higher and hospital stays were shorter than in conservative group and were statistically significant (p<0.05). Conclusion The main etiology of SBO-VA in our study was adhesions. Older age, previous hospital admission, longer abdominal pain duration, abdominal tenderness, increased inflammatory markers, and alarm signs on CT scans are the main factors for determining the need for urgent surgical exploration in patients with SBO-VA. To achieve prompt identification and intervention, it is crucial to maintain a high level of vigilance and awareness, even in individuals with no prior surgical history.
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Affiliation(s)
- Saif Ghabisha
- Department of General Surgery, School of Medicine, Ibb University, Ibb, Yemen
| | - Faisal Ahmed
- Department of Urology, School of Medicine, Ibb University, Ibb, Yemen
| | - Abdulfattah Altam
- Department of General Surgery, School of Medicine, 21 September University, Sana’a, Yemen
| | - Fouad Hassan
- Department of Nutrition and Dietetics, School of Medicine, Ibb University, Ibb, Yemen
| | - Mohamed Badheeb
- Department of Internal Medicine, Yale New-Haven Health/Bridgeport Hospital, Bridgeport, CT, USA
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Oh S, Ryu J, Shin HJ, Song JH, Son SY, Hur H, Han SU. Deep learning using computed tomography to identify high-risk patients for acute small bowel obstruction: development and validation of a prediction model : a retrospective cohort study. Int J Surg 2023; 109:4091-4100. [PMID: 37720936 PMCID: PMC10720875 DOI: 10.1097/js9.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/19/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVE To build a novel classifier using an optimized 3D-convolutional neural network for predicting high-grade small bowel obstruction (HGSBO). SUMMARY BACKGROUND DATA Acute SBO is one of the most common acute abdominal diseases requiring urgent surgery. While artificial intelligence and abdominal computed tomography (CT) have been used to determine surgical treatment, differentiating normal cases, HGSBO requiring emergency surgery, and low-grade SBO (LGSBO) or paralytic ileus is difficult. METHODS A deep learning classifier was used to predict high-risk acute SBO patients using CT images at a tertiary hospital. Images from three groups of subjects (normal, nonsurgical, and surgical) were extracted; the dataset used in the study included 578 cases from 250 normal subjects, with 209 HGSBO and 119 LGSBO patients; over 38 000 CT images were used. Data were analyzed from 1 June 2022 to 5 February 2023. The classification performance was assessed based on accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve. RESULTS After fivefold cross-validation, the WideResNet classifier using dual-branch architecture with depth retention pooling achieved an accuracy of 72.6%, an area under receiver operating characteristic of 0.90, a sensitivity of 72.6%, a specificity of 86.3%, a positive predictive value of 74.1%, and a negative predictive value of 86.6% on all the test sets. CONCLUSIONS These results show the satisfactory performance of the deep learning classifier in predicting HGSBO compared to the previous machine learning model. The novel 3D classifier with dual-branch architecture and depth retention pooling based on artificial intelligence algorithms could be a reliable screening and decision-support tool for high-risk patients with SBO.
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Affiliation(s)
- Seungmin Oh
- Department of Artificial Intelligence, Ajou University, Suwon, South Korea
| | - Jongbin Ryu
- Department of Artificial Intelligence, Ajou University, Suwon, South Korea
- Department of Software and Computer Engineering, Ajou University, Suwon, South Korea
| | - Ho-Jung Shin
- Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Jeong Ho Song
- Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Sang-Yong Son
- Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Hoon Hur
- Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
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Neupane S, Kashyap A, Pokhrel B, Pathak R, Koirala DP. Persistent Vitello-Intestinal Duct Masquerading as Acute Appendicitis: A Case Report. JNMA J Nepal Med Assoc 2023; 61:671-674. [PMID: 38289813 PMCID: PMC10566615 DOI: 10.31729/jnma.8239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Indexed: 02/01/2024] Open
Abstract
The vitello-intestinal duct normally regresses with the development. But, in certain cases, it could persist and present as Meckel's diverticulum. Here we report a case of an eight-year-old boy presenting with peri-umbilical abdominal pain, vomiting and loose stool. He was initially diagnosed and managed as acute appendicitis but did not improve, rather developed features of intestinal obstruction. Exploratory laparotomy was done which revealed persistent vitello-intestinal duct and was managed surgically. This case report highlights that in any case of suspected acute appendicitis, the complications of persistent vitello-intestinal duct should be considered as one of the differentials. Keywords appendicitis; case reports; intestinal obstruction; laparotomy; omphalomesenteric duct.
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Affiliation(s)
- Subita Neupane
- Department of Family Medicine and Emergency Medicine, Civil Service Hospital, New Baneshwor, Kathmandu, Nepal
| | - Ashutosh Kashyap
- Department of Pediatric Surgery, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Biraj Pokhrel
- Department of Pediatric Surgery, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Roshan Pathak
- Department of Pediatric Surgery, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Dinesh Prasad Koirala
- Department of Pediatric Surgery, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
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Hosseini SA, Abdzaid Akool M, Emami Meybodi AH, Hosseini SV. A Seven-Year Etiological Study of Adult Bowel Obstruction in Shiraz, Iran. ARCHIVES OF IRANIAN MEDICINE 2023; 26:241-247. [PMID: 38301086 PMCID: PMC10685864 DOI: 10.34172/aim.2023.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/19/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Bowel obstruction is a disorder in the passage of bowel contents, the etiology of which varies depending on temporal and geographical conditions. This study investigated the etiology of bowel obstruction in a large number of patients at an adult surgery referral center in southern Iran. METHODS In this cross-sectional study, we reviewed the medical records of all patients admitted to Shahid Faghihi hospital (Shiraz, Iran) between 2014 and 2020 with a diagnosis of small or large bowel obstruction. Patients with missing or obscure data on etiology were excluded. Data was collected on the patients' age, gender, history of relevant surgeries, comorbidities, cause of obstruction, site/type of obstruction, treatment, intensive care unit (ICU) admission, length of hospital stay, and outcome. Statistical analyses were made using SPSS v. 25.0. RESULTS A total of 2781 bowel obstruction patients (61.4% males, 38.6% females) with a median age of 58 (IQR 43-71) years were studied. Most responded to non-surgical treatment (61.3%). While the obstruction was mostly partial (65.5%), 94.4% of patients with complete obstruction required surgery. Small bowel obstruction (SBO) was almost three times more prevalent than large bowel obstruction (LBO). Adhesion bands were the leading cause of SBO (66.77%), while LBO was primarily due to colorectal tumors (33.9%). CONCLUSION The predominant etiology of LBO was colorectal cancer, suggesting that policymakers should improve surveillance programs to detect the condition earlier. Regarding SBO, the leading cause was adhesion bands, indicating the necessity of further efforts to reduce the rate of adhesions following intra-abdominal operations.
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Affiliation(s)
- Seyed Ali Hosseini
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- Colorectal Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammed Abdzaid Akool
- Department of Surgery, Faculty of Medicine, Jabir Ibn Hayyan Medical University, Najaf, Iraq
| | | | - Seyed Vahid Hosseini
- Colorectal Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Lewis M, Liasidis PK, Huang VP, Benjamin ER, Ghafil C, Jakob DA, Demetriades D. Small Bowel Obstruction in the Virgin Abdomen. J Gastrointest Surg 2023; 27:411-412. [PMID: 35970952 DOI: 10.1007/s11605-022-05294-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 03/02/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Meghan Lewis
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA.
| | - Panagiotis K Liasidis
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
| | - Valerie P Huang
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
| | - Elizabeth R Benjamin
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
| | - Cameron Ghafil
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
| | - Dominik A Jakob
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
| | - Demetrios Demetriades
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
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Jang Y, Jung SM, Heo TG, Choi PW, Kim JI, Jung SW, Jun H, Shin YC, Um E. Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study. Ann Coloproctol 2022; 38:423-431. [PMID: 34875819 PMCID: PMC9816557 DOI: 10.3393/ac.2021.00710.0101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/23/2021] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Most of the causes of small bowel obstruction (SBO) in patients without a history of abdominal surgery are unclear at initial assessment. This study was conducted to identify the etiology and clinical characteristics of SBO in virgin abdomens and discuss the proper management. METHODS A retrospective review involving operative cases of SBO from a single institute, which had no history of abdominal surgery, was conducted between January 2010 and December 2020. Clinical information, including radiological, operative, and pathologic findings, was investigated to determine the etiology of SBO. RESULTS A total of 55 patients were included in this study, with a median age of 57 years and male sex (63.6%) constituting the majority. The most frequently reported symptoms were abdominal pain and nausea or vomiting. Neoplasm as an underlying cause accounted for 34.5% of the cases, of which 25.5% were malignant cases. In patients aged ≥60 years (n=23), small bowel neoplasms were the underlying cause in 12 (52.2%), of whom 9 (39.1%) were malignant cases. Adhesions and Crohn disease were more frequent in patients aged <60 years. Coherence between preoperative computed tomography scans and intraoperative findings was found in 63.6% of the cases. CONCLUSION There were various causes of surgical cases of SBO in virgin abdomens. In older patients, hidden malignancy should be considered as a possible cause of SBO in a virgin abdomen. Patients with symptoms of recurrent bowel obstruction who have no history of prior abdominal surgery require thorough medical history and close follow-up.
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Affiliation(s)
- Youngjin Jang
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Sung Min Jung
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea,Correspondence to: Sung Min Jung, M.D. Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea Tel: +82-31-911-7993, Fax: +82-31-911-7319 E-mail:
| | - Tae Gil Heo
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Pyong Wha Choi
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Jae Il Kim
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Sung-Won Jung
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Heungman Jun
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Yong Chan Shin
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Eunhae Um
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
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Small Bowel Obstruction in Patients without Prior Abdominal Surgery: To Operate or Not? World J Surg 2022; 46:2919-2926. [PMID: 36059038 DOI: 10.1007/s00268-022-06719-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Surgical exploration is still considered mandatory in the setting of small bowel obstruction (SBO) in patients without prior intra-abdominal surgery. However, recent studies have challenged this 'classic' approach describing success with conservative non-surgical treatment. The aim of this study is to identify clinical, radiological and biochemical variables that may be associated with the absence of intra-abdominal pathology in patients with SBO who have not undergone previous surgery. METHODS This is a retrospective cohort study of prospectively recorded data. Patients with SBO without prior abdominal surgery who presented to a single tertiary referral medical center between 2009 and 2019 were included. RESULTS Eighty-seven patients were included of whom 61(70.0%) were allocated to the 'therapeutic exploration' group and 26 (30.0%) to the 'non-therapeutic exploration' group. Forty-eight patients (55.0%) had adhesions, 17.2% had closed-loop obstruction, 10.0% had an internal hernia, 27.6% had bowel ischemia and 5.7% had bowel necrosis. Although multiple clinical, laboratory, radiological and preoperative factors were examined, none were significantly associated with pathological findings during surgical exploration. There was no statistically significant difference in the incidence of complications when comparing between those groups. CONCLUSIONS In this series, no variables were associated with intra-abdominal pathology in patients who underwent surgery for SBO with no history of prior abdominal surgery. However, the fact that 27.0% had ischemic bowel upon surgical exploration suggests that this approach is still mandatory for this specific group of patients. Furthermore, clinicians and patients should be aware that negative exploration may be expected in up to 30.0%.
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Hirao H, Okabe H, Masuda T, Ogawa D, Uemura N, Kuroda D, Taki K, Tomiyasu S, Hirota M, Hibi T, Baba H, Sugita H. Intestinal Fluid CT Level Could Predict Pathological Small Bowel Ischemia in Small Bowel Obstruction. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03437-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Rubalcava NS, Speck KE. Current Management of Adhesive Small Bowel Obstructions in Children. Adv Pediatr 2022; 69:243-257. [PMID: 35985714 DOI: 10.1016/j.yapd.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Adhesive small bowel obstructions are a common cause of morbidity in children who underwent prior abdominal surgery. The concept of partial versus complete bowel obstruction is outdated and lacks precision to be clinically useful. Identifying patients with indications for immediate operative intervention is critical and must be recognized to limit morbidity. Clinical protocols and contrast challenge algorithms have attempted to identify patients that will resolve their bowel obstruction nonoperatively; there has been slow uptake in the pediatric patient population versus adults until recently. Incorporating predictive models and standardized contrast challenge protocols will help reduce interpractitioner variability and improve clinical outcomes.
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Affiliation(s)
- Nathan S Rubalcava
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Mott Children's Hospital, 1540 East Hospital Drive SPC 4217, Ann Arbor, MI 48109-4217, USA; Department of Surgery, Creighton University Health Science Campus, 3100 North Central Avenue, Phoenix, AZ 85012, USA
| | - K Elizabeth Speck
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Mott Children's Hospital, 1540 East Hospital Drive SPC 4217, Ann Arbor, MI 48109-4217, USA.
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Tyagunov AE, Sazhin AV, Tyagunov AA, Nechay TV, Ermakov IV. [Preoperative diagnosis of intestinal ischemia in small bowel obstruction. Only computed tomography? A multiple-center observational study]. Khirurgiia (Mosk) 2022:26-35. [PMID: 36562670 DOI: 10.17116/hirurgia202212226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the accuracy of clinical, laboratory and instrumental methods for diagnosis of intestinal ischemia following small bowel obstruction in emergency hospitals. MATERIAL AND METHODS Multiple-center observational retrospective study enrolled 158 consecutive patients with benign small bowel obstruction (SBO) treated at four hospitals between May 2017 and December 2019. The role of clinical, laboratory and instrumental diagnostic methods for intestinal ischemia was analyzed. We assessed the impact of CT and contrast-enhanced X-ray examination on survival of patients. RESULTS Laboratory parameters as criteria of ischemia following SBO were similar (leukocytosis >14·109/l (p=1.0), serum lactate >2.0 mmol/l (p=0.28), heart rate >90/min (p=0.71) and fever (p=0.74)). The only laboratory indicator with significant differences was serum sodium. Decrease in leukocytosis over time was less common in patients with ischemia (25% vs. 61.3%, p=0.012). Univariate Kaplan-Meier analysis did not establish the effect of CT on survival (7.8% [95% CI 7.6-8.0] vs. 6.5% [95% CI 6.3-6.6], p=0.786). Logistic regression revealed 6.4-fold higher chance of accurate diagnosis (ischemia/non-ischemia) in case of CT-based conclusion of ischemia (95% CI 0.025-0.85). Univariate analysis showed that the use of water-soluble contrast for adhesive SBO was associated with lower mortality (4.1% [95% CI 4.0-4.2] vs. 14.3% [95% CI 13.7-14.9], p=0.032) without assessing the comparability of groups. CONCLUSION Routine laboratory tests were not specific for intestinal ischemia. Therefore, they should not be considered as the only criteria for surgical tactics in intestinal obstruction. Only CT showed acceptable diagnostic accuracy, and, apparently, only this method has real prospects for improving the quality of diagnosis due to technical support, training of surgeons and specialists for diagnosis.
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Affiliation(s)
- A E Tyagunov
- Moscow Multidisciplinary Clinical Center "Kommunarka", Moscow, Russia
| | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Tyagunov
- Buyanov Municipal Clinical Hospital No. 12, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I V Ermakov
- Pirogov Russian National Research Medical University, Moscow, Russia
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Tyagunov AE, Fedorov AV, Nechay TV, Tyagunov AA, Sazhin AV. [Surgical approach for small bowel obstruction in the Russian Federation. National survey of surgeons]. Khirurgiia (Mosk) 2022:5-17. [PMID: 35593623 DOI: 10.17116/hirurgia20220515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To study surgical approach for small bowel obstruction (SBO) regarding national and international guidelines. MATERIAL AND METHODS Considering literature data, national and international guidelines and clinical practice, we have formulated 15 questions regarding surgical approach for non-neoplastic SBO. Questions were sent by e-mail to the members of the Russian Society of Surgeons. Survey lasted 60 days. We used the program that provides the respondent with the possibility of visual control of survey results. Survey results were compared with national and international clinical guidelines, Russian- and English-language scientific publications. Restriction of the number of votes >1 and identification of respondents were not provided by the program. There was no reward for survey. A summary is provided on the main issues. RESULTS There were 557 respondents (3.0% of surgeons in the Russian Federation). We obtained 481-620 answers for each question. CONCLUSION This study is a valuable tool for primary assessment of current surgical practice for SBO in the Russian Federation. Study design did not imply conclusions on the optimal strategy based on opinions of majority of respondents. According to our survey, a significant number of respondents use the treatment strategy that differ from clinical guidelines. Their approach is based on their own clinical experience and local guidelines for the treatment of SBO. Less than half of the answers matched to national clinical guidelines, less than 10% - to the WSES guidelines. Despite the formal coincidence of some statements in national clinical guidelines and English-language recommendations, significant nonconformities require scientific discussion.
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Affiliation(s)
- A E Tyagunov
- Municipal Clinical Hospital No. 40, Moscow, Russia
| | - A V Fedorov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Tyagunov
- Buyanov Municipal Clinical Hospital No.12, Moscow, Russia
| | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
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Mahony CR, Traynor MD, Knight AW, Hughes JD, Hernandez MC, Finnesgard EJ, Musa J, Selby SL, Rivera M, Kim BD, Heller SF, Zielinski MD. Small bowel obstruction managed without hospital admission: A safe way to reduce both cost and time in the hospital? Surgery 2021; 171:1665-1670. [PMID: 34815095 DOI: 10.1016/j.surg.2021.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Small bowel obstruction management has evolved to incorporate the Gastrografin challenge. We expanded its use to the emergency department observation unit, potentially avoiding hospital admission for highly select small bowel obstruction patients. We hypothesized that the emergency department observation unit small bowel obstruction protocol would reduce admissions, costs, and the total time spent in the hospital without compromising outcomes. METHODS We reviewed patients who presented with small bowel obstruction from January 2015 to December 2018. Patients deemed to require urgent surgical intervention were admitted directly and excluded. The emergency department observation unit small bowel obstruction guidelines were introduced in November 2016. Patients were divided into pre and postintervention groups based on this date. The postintervention group was further subclassified to examine the emergency department observation unit patients. Cost analysis for each patient was performed looking at number of charges, direct costs, indirect cost, and total costs during their admission. RESULTS In total, 125 patients were included (mean age 69 ± 14.3 years). The preintervention group (n = 62) and postintervention group (n = 63) had no significant difference in demographics. The postintervention group had a 51% (36.7 hours, P < .001) reduction in median duration of stay and a total cost reduction of 49% (P < .001). The emergency department observation unit subgroup (n = 46) median length of stay was 23.6 hours. The readmission rate was 16% preintervention compared to 8% in the postintervention group (P = .18). CONCLUSION Management of highly selected small bowel obstruction patients with the emergency department observation unit small bowel obstruction protocol was associated with decreased length of stay and total cost, without an increase in complications, surgical intervention, or readmissions.
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Affiliation(s)
- Cillian R Mahony
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.
| | - Michael D Traynor
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Ariel W Knight
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Joy D Hughes
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Matthew C Hernandez
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Finnesgard
- Department of Vascular Surgery, University of Massachusetts Memorial Health Care, Worcester, MA
| | - Juna Musa
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Sasha L Selby
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Mariela Rivera
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Brian D Kim
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Stephanie F Heller
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Martin D Zielinski
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
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14
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Amara Y, Leppaniemi A, Catena F, Ansaloni L, Sugrue M, Fraga GP, Coccolini F, Biffl WL, Peitzman AB, Kluger Y, Sartelli M, Moore EE, Di Saverio S, Darwish E, Endo C, van Goor H, Ten Broek RP. Diagnosis and management of small bowel obstruction in virgin abdomen: a WSES position paper. World J Emerg Surg 2021; 16:36. [PMID: 34217331 PMCID: PMC8254282 DOI: 10.1186/s13017-021-00379-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Yousef Amara
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of General Surgery, The Baruch Padeh Medical Centre, Poriya, Israel
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Fausto Catena
- Department of General Surgery, Parma University Hospital, Parma, Italy
| | - Luca Ansaloni
- General Emergency And Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM), Unicamp Campinas, São Paulo, Brazil
| | | | - Walter L Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, Hawaii, USA
| | - Andrew B Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus Haifa, Haifa, Israel
| | | | | | | | - Esfo Darwish
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Chikako Endo
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Richard P Ten Broek
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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15
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Tyagunov AE, Tyagunov AA, Nechay TV, Vinogradov VN, Kurashinova LS, Sazhin AV. [Timing of surgery, intestinal ischemia and other real factors of mortality in acute adhesive small bowel obstruction: a multiple-center study]. Khirurgiia (Mosk) 2021:26-35. [PMID: 33710823 DOI: 10.17116/hirurgia202103126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To analyze the factors of mortality in patients with acute adhesive small bowel obstruction (AASBO). MATERIAL AND METHODS A retrospective multiple-center study included 143 (85.6%) patients with AASBO out of 167 consecutive patients with small bowel obstruction for the period 2017-2019. All patients were divided into 3 groups: early surgery group (within 12 hours after admission), late surgery (after 12 hours), non-surgical management group. The outcomes and Kaplan-Meier survival were compared in all groups. RESULTS AASBO was resolved without surgery in 77 (53.8%) patients 19.6±17.4 (M=14) hours. In the Early Surgery Group (n=36), 24 patients had strangulation, 12 ones had non-strangulated bowel obstruction. In the Late Surgery Group (n=30), 15 patients had strangulation and 15 ones had no strangulation. Mortality was similar in early and late surgery (p=0.287), early and late surgery in patients with strangulation (p=0.940), early and late surgery in patients without strangulation (p=0.76). Patients died (n=10) after surgery only. Thus, postoperative mortality was 15.2%, overall mortality - 7.0%. All patients who underwent surgery after 24 hours (n=14) survived. Surgery increased the mortality risk compared to non-surgical management (95% CI 0 - 15.9, p=0.001). There was no effect of surgery time (more or less than 12 hours) on mortality for strangulation (95% CI 13.0-16.7, p 0.788) and non-strangulated obstruction (95% CI 29.4-5.4, p=0.061), bowel resection (95% CI 33.3-14.0, p=0.187), presence of bowel ischemia (95% CI 14.3-17.9, p 0.613). CONCLUSION Delayed surgery may be advisable in patients with AASBO and no obvious signs of strangulation due to less mortality.
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Affiliation(s)
- A E Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Tyagunov
- Buyanov Municipal Clinical Hospital No 12, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - V N Vinogradov
- Pirogov Municipal Clinical Hospital No 1, Moscow, Russia
| | | | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
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16
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Non-operative management of small bowel obstruction in virgin abdomen: a systematic review. Surg Today 2021; 51:1558-1567. [PMID: 33481087 DOI: 10.1007/s00595-020-02210-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 10/22/2022]
Abstract
The aim of this study was to systematically review the feasibility and safety of non-operative management of small bowel obstruction (SBO) in virgin abdomen. A systematic review was performed through December 2019. The primary outcome was the resolution of non-operative management of SBO in virgin abdomen. Secondary outcomes were the etiology of SBO and findings of exploratory laparotomy. Six studies were included in the analysis. Of the 442 patients, 2 with metastatic cancer received palliative care, and the management in 26 was not reported, so these patients were excluded. A total of 414 patients were ultimately analyzed, including 203 patients (49%) who were managed non-operatively and 211 (51%) who underwent surgical management. Of the 203 managed non-operatively, the condition of 194 (96%) was resolved without further intervention. The remaining 9 (5%) patients failed non-operative management and ultimately required surgery. Of the 211 patients who underwent surgical exploration, only 137 had their intraoperative findings reported. Adhesions (n = 67; 49%) were the main cause, followed by malignancy (n = 14; 10%) and others (n = 33; 24%). No cause was found in 23 patients (17%). In highly select cases of SBO with virgin abdomen, non-operative management can be attempted if patients are clinically stable and computed tomography does not demonstrate concerning features or obvious pathology. Further well-designed prospective studies will be required prior to the introduction of this concept in clinical practice, as current evidence remains heterogeneous.
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17
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Figueiredo SMPD, Demola S. Successful use of water-soluble contrast in patients with small bowel obstruction and virgin abdomen: A case report. Int J Surg Case Rep 2021; 79:94-96. [PMID: 33453466 PMCID: PMC7811061 DOI: 10.1016/j.ijscr.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/02/2021] [Accepted: 01/02/2021] [Indexed: 11/25/2022] Open
Abstract
Trial of nonoperative management is standard of care for adhesive SBO. Prior surgery is the most common cause of adhesions. Management of SBO in patients without prior surgery is a challenge. This is a case of SBO in a virgin abdomen patient successfully managed nonoperatively.
Introduction and importance Nonoperative management of adhesive SBO is well established but remains a challenge in patients without prior abdominal surgery. We aim to report a case of successful nonoperative management with the use of enteral hypertonic water-soluble contrast administration in a patient with virgin abdomen. Case presentation A healthy 24-year old man with no previous surgery presented to the emergency room with one day of abdominal pain. A CT abdomen and pelvis was consistent with SBO without clear anatomic etiology. The patient refused surgical intervention, so we performed a trial of nonoperative management. On hospital day 2, a repeat CT A/P with enterally administered water-soluble contrast showed resolution of SBO. The patient has had no symptoms since hospital discharge on 6 months follow up. Clinical discussion Small bowel obstruction is most commonly secondary to adhesions from prior surgeries. Even in patients with virgin abdomen, adhesions are the cause of SBO in 53%–73%. Recent studies in patients with virgin abdomen showed that 92.1% that underwent nonoperative management did not have a recurrence of SBO with mean follow up of 4.5 years. The use of water-soluble contrast in patients with virgin abdomen was reported to have 92–97% success rate. A meta-analysis showed a pooled prevalence of 7.7% of malignant etiology of SBO in these patients, more common with previous SBO admission or history of malignancy. Conclusion Nonoperative management with the therapeutic use of hypertonic water-soluble contrast is a viable treatment option in select cases and avoids the morbidity of surgical exploration.
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Affiliation(s)
| | - Sara Demola
- Department of Surgery, University of Texas Medical Branch Hospital, 301 University Blvd, Galveston, TX 77555, United States
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18
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Yang TWW, Prabhakaran S, Bell S, Chin M, Carne P, Warrier SK, Skinner S, Kong JC. Non-operative management for small bowel obstruction in a virgin abdomen: a systematic review. ANZ J Surg 2020; 91:802-809. [PMID: 33084181 DOI: 10.1111/ans.16392] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Small bowel obstruction (SBO) is a common general surgical presentation and there has been a shift towards non-operative management (NOM) for patients with previous abdominal surgery. Historically, exploratory surgery has been mandated for SBO in patients with a virgin abdomen. However, there is increasing evidence for NOM in this group of patients. METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search was undertaken between 1995 and 2020 on Ovid MEDLINE, EMBASE and PubMed. Primary outcome measures were success and failure rates, whereas secondary outcome measures were morbidity, mortality rates and identifying underlying aetiologies. RESULTS Six observational studies were included, with 205 patients in the NOM and 211 patients in the operative group. There was a high success rate of 95.6% and low morbidity rate of 3.1% in the NOM group compared to 88.6% and 26% in the operative group, respectively. Both groups reported no mortalities. The most common aetiologies for SBO in a virgin abdomen were adhesions (63%), malignancy (11%), foreign body/bezoar (5%), internal hernia (4%) and volvulus (4%). CONCLUSION NOM for SBO is a safe and feasible option for a select group of clinically stable patients with a virgin abdomen without features of closed-loop obstruction. Adhesions are the most common cause of SBO in this group of patients. Further large-scale prospective clinical studies with standardized NOM modality, homogenous clinical resolution indicators and long-term follow-up data are warranted to allow for quantitative analysis to reinforce this evidence.
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Affiliation(s)
- Tze W W Yang
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Swetha Prabhakaran
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephen Bell
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Martin Chin
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter Carne
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Stewart Skinner
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph C Kong
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
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19
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Morani AC, Hanafy AK, Marcal LP, Subbiah V, Le O, Bathala TK, Elsayes KM. Imaging of acute abdomen in cancer patients. Abdom Radiol (NY) 2020; 45:2287-2304. [PMID: 31758230 DOI: 10.1007/s00261-019-02332-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The pattern of disease causing acute abdominal pain has changed over last few decades, some of this has been attributed to intraabdominal cancers. The most common acute abdominal complaints in cancer patients are related to the gastrointestinal system. Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of. This article focuses on imaging illustrations with differential diagnosis for various emergency scenarios related to acute abdomen specifically in oncologic settings.
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Affiliation(s)
- Ajaykumar C Morani
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA.
| | - Abdelrahman K Hanafy
- Diagnostic Radiology, The University of Texas Health Science Centre at San Antonio, San Antonio, TX, 78229, USA
| | - Leonardo P Marcal
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Vivek Subbiah
- Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Ott Le
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Tharakeshwara K Bathala
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
| | - Khaled M Elsayes
- Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holocombe Blvd, Houston, TX, 77030, USA
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20
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Mansoori B, Vasan V, Xi Y, Fielding JR. Variations in use of "water soluble contrast challenge" for small bowel obstruction among academic radiologists: results of a national survey. Abdom Radiol (NY) 2020; 45:1050-1056. [PMID: 32052131 DOI: 10.1007/s00261-020-02436-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To assess the frequency and indications for use of oral water-soluble contrast challenge as a diagnostic test for small bowel obstruction in four regions of the USA. MATERIALS AND METHODS We distributed a 9-question web-based survey to the abdominal section heads of academic radiology departments throughout the USA (N = 97). The questions pertained to use of water-soluble contrast for management of small bowel obstruction. Descriptive statistics and Fisher's exact tests were used for data analysis. RESULTS The overall response rate was 46%. Eighty percent of the responding hospitals had more than 500 beds in operation. Water-soluble contrast challenge was considered standard of care for management of non-operative small bowel obstruction in 60% of the responding radiology departments. The majority of the responding departments (41%) performed 2-8 contrast challenge studies per month on average. The most frequent indication for the study was distinguishing partial vs complete bowel obstruction. Eighty percent of the responding radiologists believed that the contrast challenge is useful for management of small bowel obstruction. Overall, there was no statistically significant difference in frequency and indication for use of water-soluble contrast challenge based on geographic location. CONCLUSION The water-soluble contrast challenge was considered standard of care for non-operative management of small bowel obstruction in majority of the academic radiology departments represented in this survey. Surgeons were referring clinicians in every case. The most common clinical indication for the study was distinguishing partial versus complete small bowel obstruction.
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Affiliation(s)
- Bahar Mansoori
- Abdominal Imaging Division, Department of Radiology, University of Washington Medical Center, Seattle, WA, USA.
| | - Vasantha Vasan
- Abdominal Imaging Division, Department of Radiology, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - Yin Xi
- Abdominal Imaging Division, Department of Radiology, University of Texas, Southwestern Medical Center, Dallas, TX, USA.,Department of Population and Data Sciences, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - Julia R Fielding
- Abdominal Imaging Division, Department of Radiology, University of Texas, Southwestern Medical Center, Dallas, TX, USA
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21
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Abstract
Nearly 3 million patients are hospitalized every year for emergent gastrointestinal (GI) surgical problems and nearly one third of those will require surgery. This article reviews the scope of GI surgical emergencies within the context of emergency general surgery (EGS), costs of care, overview of several common GI surgical problems, and traditional and emerging treatment modalities. This article also argues for ongoing work in the area of risk assessment for EGS, and describes quality metrics as well as outcomes of care for these patients.
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22
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The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction. J Trauma Acute Care Surg 2019; 84:372-378. [PMID: 29117026 DOI: 10.1097/ta.0000000000001736] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study. METHODS Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed. RESULTS There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1-3] vs. 3 [2-4], p = 0.008), small bowel resection (2 [2-2] vs. 3 [2-4], p < 0.0001), postoperative temporary abdominal closure (2 [2-3] vs. 3 [3-4], p < 0.0001), and stoma creation (2 [2-3] vs. 3 [2-4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade. CONCLUSION The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms. LEVEL OF EVIDENCE Prognostic, level III.
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23
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Strajina V, Kim BD, Zielinski MD. Small bowel obstruction in a virgin abdomen. Am J Surg 2019; 218:521-526. [PMID: 30885455 DOI: 10.1016/j.amjsurg.2019.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/29/2019] [Accepted: 02/03/2019] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Surgical exploration is still considered mandatory in the setting of small bowel obstruction (SBO) and a virgin abdomen by some large centers. The aim of this study is to determine the etiology of SBO in patients without prior abdominal operation. METHODS Retrospective review of the patients treated for SBO and virgin abdomen at the Mayo Clinic between 2006 and 2016 was performed. Follow up data, operative and pathologic findings were examined to determine the etiology of SBO. RESULTS Sixty patients met inclusion criteria; abdominal exploration was performed in 50 patients (83%) and 10 patients (17%) were managed non-operatively. Exploration was therapeutic in 29 (58%), negative in 20 (40%) and non-therapeutic in one patient (2%). Overall, 8 patients (13%) were diagnosed with a malignancy: right-sided colon cancer (n = 3), small bowel (SB) neuroendocrine tumor (n = 2), SB lymphoma (n = 2) and carcinomatosis peritonei (n = 1); Upon retrospective review, both SB neuroendocrine tumors and one SB lymphoma were visible on the initial imaging. Leukocytosis (p = .03) and no recent weight loss (p = .04) were associated with negative exploration. CONCLUSION Patients with SBO and virgin abdomen frequently have a benign etiology. Careful imaging review directed at subtle signs of an underlying malignancy is warranted. If non-operative management is chosen, close follow up is essential and it should include a careful personal and family history as well as updated colonoscopy.
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Affiliation(s)
| | - Brian D Kim
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
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24
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Abstract
PURPOSE To analyze CT signs of bowel ischemia in patients with surgical bowel obstruction, and thereby improve CT diagnosis in this common clinical scenario. Surgical and histopathological findings were used as the reference standard. METHODS We retrospectively analyzed CT findings in patients brought to surgery for bowel obstruction over 13 years. Etiology of obstruction (adhesion, hernia, etc.) was recorded. Specific CT features of acute mesenteric ischemia (AMI) were analyzed, including bowel wall thickening, mucosal hypoenhancement, and others. RESULTS 173 cases were eligible for analysis. 21% of cases were positive for bowel ischemia. Volvulus, internal hernia, and closed-loop obstructions showed ischemia rates of 60%, 43%, and 43%; ischemia rate in obstruction from simple adhesion was 21%. Patients with bowel obstruction related to malignancy were never ischemic. Sensitivities and specificities for CT features predicting ischemia were calculated, with wall thickening, hypoenhancement, and pneumatosis showing high specificity for ischemia (86%-100%). CONCLUSION Wall thickening, hypoenhancement, and pneumatosis are highly specific CT signs of ischemia in the setting of obstruction. None of the evaluated CT signs were found to be highly sensitive. Overall frequency of ischemia in surgical bowel obstruction is 21%, and 2-3 times that for complex obstructions (volvulus, closed loop, etc.). Obstructions related to malignancy virtually never become ischemic.
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25
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Hernandez MC, Birindelli A, Bruce JL, Buitendag JJP, Kong VY, Beuran M, Aho JM, Negoi I, Clarke DL, Di Saverio S, Zielinski MD. Application of the AAST EGS Grade for Adhesive Small Bowel Obstruction to a Multi-national Patient Population. World J Surg 2018; 42:3581-3588. [PMID: 29770872 DOI: 10.1007/s00268-018-4671-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) has demonstrated to be a valid tool in North American patient populations. Using a multi-national patient cohort, we retrospectively assessed the validity the AAST ASBO grading system and estimated disease severity in a global population in order to correlate with several key clinical outcomes. METHODS Multicenter retrospective review during 2012-2016 from four centers, Minnesota USA, Bologna Italy, Pietermaritzburg South Africa, and Bucharest Romania, was performed. Adult patients (age ≥ 18) with ASBO were identified. Baseline demographics, physiologic parameters, laboratory results, operative and imaging details, outcomes were collected. AAST ASBO grades were assigned by independent reviewers. Univariate and multivariable analyses with odds ratio (OR) and 95% confidence intervals (CIs) were performed. RESULTS There were 789 patients with a median [IQR] age of 58 [40-75] years; 47% were female. The AAST ASBO grades were I (n = 180, 23%), II (n = 443, 56%), III (n = 87, 11%), and IV (n = 79, 10%). Successful non-operative management was 58%. Conversion rate from laparoscopy to laparotomy was 33%. Overall mortality and complication and temporary abdominal closure rates were 2, 46, and 4.7%, respectively. On regression, independent predictors for mortality included grade III (OR 4.4 95%CI 1.1-7.3), grade IV (OR 7.4 95%CI 1.7-9.4), pneumonia (OR 5.6 95%CI 1.4-11.3), and failing non-operative management (OR 2.4 95%CI 1.3-6.7). CONCLUSION The AAST EGS grade can be assigned with ease at any surgical facility using operative or imaging findings. The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research. Disease severity and outcomes varied between countries. LEVEL OF EVIDENCE III Study type Retrospective multi-institutional cohort study.
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Affiliation(s)
- Matthew C Hernandez
- Division of Trauma, Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Arianna Birindelli
- Department of Surgery, Maggiore Hospital, Bologna, Italy
- Department of Surgery, NHS, Queen Elizabeth University Hospital, Birmingham, UK
| | - John L Bruce
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Johannes J P Buitendag
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Victory Y Kong
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Mircea Beuran
- Department of General Surgery, Emergency Hospital of Bucharest, Carol Davila University of Medicine and Pharmacy of Bucharest, Bucharest, Romania
| | - Johnathon M Aho
- Division of Trauma, Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ionut Negoi
- Department of General Surgery, Emergency Hospital of Bucharest, Carol Davila University of Medicine and Pharmacy of Bucharest, Bucharest, Romania
| | - Damian L Clarke
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Salomone Di Saverio
- Department of Surgery, Maggiore Hospital, Bologna, Italy
- Department of Surgery, NHS, Queen Elizabeth University Hospital, Birmingham, UK
- Addenbrookes Hospital, Cambridge University Hospitals, NHS, University of Cambridge, Cambridge, UK
| | - Martin D Zielinski
- Division of Trauma, Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Comparisons of the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center. Int J Colorectal Dis 2018; 33:1617-1625. [PMID: 29679151 DOI: 10.1007/s00384-018-3052-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Intestinal obstruction is a leading cause of patient mortality and the most common reason for emergent operation in colorectal surgery. The influence of inter-hospital transfer on patients' outcomes varies greatly in different diseases. We aimed to compare the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center. METHODS All intestinal obstruction patients operated in Cleveland Clinic from Jan 2012 to Dec 2016 were collected from a prospectively maintained database. Preoperative characteristics; surgical outcomes, including intraoperative complication, postoperative complication, readmission, reoperation, and postoperative 30-day mortality; and medical cost were collected. All parameters were compared between two groups before and after propensity score match. Multivariate logistic analysis was used to explore risk factors of surgical outcomes. RESULTS A total of 576 patients were included, with 75 in the transferred group and 501 in the directly admitted group. Before match, the transferred patients had longer waiting interval from admission to surgery (p < 0.001), more contaminated or infected wounds (p = 0.02), different surgical procedures (p = 0.02), and similar surgical outcomes and total medical cost (all p > 0.05), compared with the directly admitted group. Multivariate analysis showed that inter-hospital transfer was not an independent predictor of any surgical outcome. After matching to balance the preoperative characteristics between two groups, no significant differences were identified in all surgical outcomes and total medical cost between two groups (all p > 0.05). CONCLUSIONS Compared with directly admitted patients, transferred intestinal obstruction patients are associated with similar surgical outcomes and similar medical costs.
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Ozturk E, van Iersel M, Stommel MM, Schoon Y, Ten Broek RR, van Goor H. Small bowel obstruction in the elderly: a plea for comprehensive acute geriatric care. World J Emerg Surg 2018; 13:48. [PMID: 30377439 PMCID: PMC6196030 DOI: 10.1186/s13017-018-0208-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 09/24/2018] [Indexed: 12/16/2022] Open
Abstract
Small bowel obstruction is one of the most frequent emergencies in general surgery, commonly affecting elderly patients. Morbidity and mortality from small bowel obstruction in elderly is high. Significant progress has been made in the diagnosis and management of bowel obstruction in recent years. But little is known whether this progress has benefitted outcomes in elderly patients, particularly those who are frail or have a malignancy as cause of the obstruction, and when considering quality of life and functioning as outcomes. In this review, we discuss the specific challenges and needs of elderly in diagnosis and treatment of small bowel obstruction. We address quality of life aspects and explore how the concept of geriatric assessment can be utilized to improve decision-making and outcomes for elderly patients with a small bowel obstruction.
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Affiliation(s)
- Ekin Ozturk
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Marianne van Iersel
- 2Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martijn Mwj Stommel
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Yvonne Schoon
- 2Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands.,3Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Richard Rpg Ten Broek
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Harry van Goor
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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28
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Köstenbauer JK. Managing Adhesive Small Bowel Obstruction with Water-Soluble Contrast Should Be Protocolized: A Retrospective Analysis. Surg J (N Y) 2018; 4:e123-e128. [PMID: 30038961 PMCID: PMC6054586 DOI: 10.1055/s-0038-1666781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/16/2018] [Indexed: 12/13/2022] Open
Abstract
Aim
Current literature emphasizes the effectiveness of computed tomography (CT) and water-soluble contrast agent, Gastrografin, in the investigation of adhesive small bowel obstruction (ASBO). As there is no management protocol for ASBO at our institution, the aim of this study was to determine the effect of imaging methods—CT, Gastrografin challenge (GC), or plain-film X-ray—on patient outcomes in a clinical setting.
Methods
All 163 emergency presentations of ASBO during the study period between December 2010 and September 2012 were collected retrospectively. Cases were divided into three groups: CT with oral contrast, GC, or plain-film X-ray only. The primary outcome was time to theater.
Results
Patients investigated with X-ray only were significantly less likely to require surgery (6% in plain-film X-ray vs. 35% and 20% in CT and GC, respectively;
p
= 0.003). In cases requiring surgery, GC was associated with a 24-hour longer time to imaging than CT (
p
< 0.001). The time to theater was 71:25 hours for GC versus 46:39 for CT (
p
= 0.039). There was no significant difference in bowel resection or complication rates.
Conclusion
Patients undergoing water-soluble contrast studies were subjected to unnecessary delays in their clinical course. These delays are costly and avoidable. The development and implementation of an evidence-based protocol for the management of small bowel obstruction is strongly recommended. The lack of a protocol likely caused significant delays in Gastrografin administration, reducing its known benefits for clinical decision-making and length of stay.
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Affiliation(s)
- Jakob K Köstenbauer
- Department of Surgery, University of New South Wales, Wagga Wagga Rural Referral Hospital, Wagga Wagga, New South Wales, Australia
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29
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Köstenbauer J, Truskett PG. Current management of adhesive small bowel obstruction. ANZ J Surg 2018; 88:1117-1122. [PMID: 29756678 DOI: 10.1111/ans.14556] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 01/25/2018] [Accepted: 02/28/2018] [Indexed: 12/20/2022]
Abstract
Small bowel obstruction is a common and significant surgical presentation. Approximately 30% of presentations will require surgery during admission. The great challenge of adhesive small bowel obstruction (ASBO) management is the early detection of silent intestinal ischaemia in patients initially deemed suitable for conservative therapy. Recent literature emphasizes the effectiveness of computed tomography enterography and water-soluble contrast studies in the management of ASBO. Low-volume undiluted water-soluble contrast has been shown to have both triage and therapeutic value in the management of ASBO. Their use has been demonstrated to reduce the need for surgery to below 20%. There has also been growing interest in clinicoradiological algorithms which aim to predict ischaemia early in the course of presentation. The aim of this review is to summarize the latest evidence and clarify previous uncertainties, specifically regarding the duration of conservative treatment, timing of contrast studies and the reliability of predictive algorithms. Based on this latest evidence, we have formulated a management protocol which aims to integrate these latest developments and formalize a strategy for best management in ASBO.
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Affiliation(s)
- Jakob Köstenbauer
- Rural Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Surgery, Wagga Wagga Rural Referral Hospital, Wagga Wagga, New South Wales, Australia
| | - Philip G Truskett
- Rural Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
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30
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Blackwell RH, Kothari AN, Shah A, Gange W, Quek ML, Luchette FA, Flanigan RC, Kuo PC, Gupta GN. Adhesive Bowel Obstruction Following Urologic Surgery: Improved Outcomes with Early Intervention. Curr Urol 2018; 11:175-181. [PMID: 29997459 DOI: 10.1159/000447215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 08/25/2017] [Indexed: 11/19/2022] Open
Abstract
Objective To describe the long-term incidence of adhesive bowel obstruction following major urologic surgery, and the effect of early surgery on perioperative outcomes. Methods The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida (2006-2011) were used to identify major urologic oncologic surgery patients. Subsequent adhesive bowel obstruction admissions were identified and Kaplan-Meier time-to-event analysis was performed. Early surgery for bowel obstruction was defined as occurring on-or-before hospital-day four. The effects of early surgery on postoperative minor/moderate complications (wound infection, urinary tract infection, deep vein thrombosis, and pneumonia), major complications (myocardial infarction, pulmonary embolism, and sepsis), death, and postoperative length-of-stay were assessed. Results Major urologic surgery was performed on 104,400 patients, with subsequent 5-year cumulative incidence of adhesive bowel obstruction admission of 12.4% following radical cystectomy, 3.3% following kidney surgery, and 0.9% following prostatectomy. During adhesive bowel obstruction admission, 71.6% of patients were managed conservatively and 28.4% surgically. Early surgery was performed in 65.4%, with decreased rates of minor/moderate complications (18 vs. 30%, p = 0.001), major complications (10 vs. 19%, p = 0.002), and median postoperative length of stay (8 vs. 11 days, p < 0.001) compared with delayed surgery. On multivariate analysis early surgery decreased the odds of minor/ moderate complications by 43% (p = 0.01), major complications by 45% (p = 0.03), and postoperative length of stay by 3.1 days (p = 0.01). Conclusion Adhesive bowel obstruction is a significant long-term sequela of urologic surgery, for which early surgical management may be associated with improved perioperative outcomes.
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Affiliation(s)
- Robert H Blackwell
- Department of Urology, Loyola University Medical Center, Maywood, IL.,the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Anai N Kothari
- Department of Surgery, Loyola University Medical Center, Maywood, IL.,the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Arpeet Shah
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - William Gange
- the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Marcus L Quek
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Fred A Luchette
- Department of Surgery, Loyola University Medical Center, Maywood, IL.,Department of Surgical Services, Edward Hines Jr Veterans Administration Medical Center, Hines
| | - Robert C Flanigan
- Department of Urology, Loyola University Medical Center, Maywood, IL.,the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Paul C Kuo
- Department of Surgery, Loyola University Medical Center, Maywood, IL.,the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Gopal N Gupta
- Department of Urology, Loyola University Medical Center, Maywood, IL.,Department of Surgery, Loyola University Medical Center, Maywood, IL.,the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
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Lilly CM, Swami S, Liu X, Riker RR, Badawi O. Five-Year Trends of Critical Care Practice and Outcomes. Chest 2017; 152:723-735. [PMID: 28800866 DOI: 10.1016/j.chest.2017.06.050] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/06/2017] [Accepted: 06/23/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Longitudinal analyses of large, detailed adult critical care datasets provide insights into practice trends and generate useful outcome and process benchmarks. METHODS Data representing 991,571 consecutive critical care visits to 160 US adult ICUs from 2009 to 2013 from the eICU Research Institute clinical practice database were used to quantitate patient characteristics, APACHE IV-based acuity predictions, treatments, and outcomes. Analyses for changes over time were performed for patient characteristics, entry and discharge locations, primary admission diagnosis, treatments, adherence to consensus ICU best practices, length of stay (LOS), and inpatient mortality. RESULTS We detected significant trends for increasing age, BMI, and risk of mortality, higher frequency of admission from an ED and stepdown unit, and more frequent hospital discharge to substance abuse centers and skilled nursing facilities. Significantly more patients were admitted for sepsis, emphysema, coma, congestive heart failure, diabetic ketoacidosis, and fewer were admitted for asthma, unspecified chest pain, coronary artery bypass graft, and stroke care. The frequency of noninvasive mechanical ventilation and adherence to critical care best practices significantly increased, whereas the duration of renal replacement therapies, frequency of transfusions, antimicrobial use, critical care complications, LOS, and inpatient mortality decreased. CONCLUSIONS Analyses of patients, practices, and outcomes from a large geographically dispersed sample of adult ICUs revealed trends of increasing age and acuity, higher rates of adherence to best practice, use of noninvasive mechanical ventilation, and decreased use of antimicrobials, transfusions, and duration of renal replacement therapies. Acuity-adjusted LOS and in hospital mortality decreased.
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Affiliation(s)
- Craig M Lilly
- Departments of Medicine, Anesthesiology, and Surgery, the Clinical and Population Health Research Program, and the Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA.
| | | | | | - Richard R Riker
- Maine Medical Center, Tufts University School of Medicine, Boston, MA
| | - Omar Badawi
- Philips Healthcare, Baltimore, MD; Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
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Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction. J Trauma Acute Care Surg 2017; 83:47-54. [DOI: 10.1097/ta.0000000000001499] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Value of MDCT and Clinical and Laboratory Data for Predicting the Need for Surgical Intervention in Suspected Small-Bowel Obstruction. AJR Am J Roentgenol 2017; 208:785-793. [PMID: 28328258 DOI: 10.2214/ajr.16.16946] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The purpose of this article is to assess the value of a large panel of clinical and MDCT variables in patients with suspected small-bowel obstruction (SBO) for predicting urgent surgical intervention (< 72 hours), bowel ischemia, and bowel resection. MATERIALS AND METHODS MDCT studies performed at admission for 179 nonconsecutive adults (mean age, 55.8 years; 86 men and 93 women) with suspected SBO were retrospectively reviewed by three board-certified radiologists. In addition to assessing individual CT features, each radiologist scored the overall likelihood of each main outcome measure using a 5-point scale. All relevant clinical and laboratory data were abstracted from electronic medical record review. Univariate and multivariate analyses were performed. RESULTS Among all 179 patients with suspected SBO, 56 (31.3%) underwent surgical intervention within 72 hours, 10 (5.6%) had ischemia at surgery, and nine (5.0%) required small-bowel resection. On univariate analysis, multiple CT findings were highly significant (p < 0.01) for predicting the main surgical outcomes, including degree of obstruction, 5-point radiology likelihood scores, and the presence of a transition point, closed loop, and mesenteric congestion. None of the objective clinical or laboratory variables (including serum lactate level) reached this level of significance. At multivariate analysis, forward stepwise logistic regression with 0.05 significance level cutoff included both degree of obstruction (p < 0.001) and closed loop (p < 0.01), with the presence of a transition point showing a trend toward significance (p = 0.081). CONCLUSION A number of findings at abdominal MDCT are associated with the need for surgery and other important surgical outcomes in patients with suspected SBO. Overall radiologist impression of need for surgical intervention was a better predictor than any clinical or laboratory parameter.
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Ng YYR, Ngu JCY, Wong ASY. Small bowel obstruction in the virgin abdomen: time to challenge surgical dogma with evidence. ANZ J Surg 2016; 88:91-94. [PMID: 27561369 DOI: 10.1111/ans.13714] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 04/23/2016] [Accepted: 07/04/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although adhesions account for more than 70% of small bowel obstruction (SBO), they are thought to be less likely aetiologies in patients without previous abdominal surgery. Expedient surgery has historically been advocated as prudent management in these patients. Emerging evidence appears to challenge such a dogmatic approach. METHODS A retrospective analysis was performed in all SBO patients with a virgin abdomen admitted between January 2012 and August 2014. Patients with obstruction secondary to abdominal wall hernias were excluded. Patient demographics, clinical presentation, management strategy and pathology involved were reviewed. RESULTS A total of 72 patients were included in the study. The majority of patients were males (66.7%), with a median age of 58 years (range: 23-101). Abdominal pain (97%) and vomiting (86%) were the most common presentations while abdominal distention (60%) and constipation (25%) were reported less frequently. Adhesions accounted for the underlying cause in 44 (62%) patients. Other aetiologies included gallstone ileus (n = 5), phytobezoar (n = 5), intussusception (n = 4), internal herniation (n = 4), newly diagnosed small bowel tumour (n = 3), mesenteric volvulus (n = 3), stricture (n = 3) and Meckel's diverticulum (n = 1). Twenty-nine (40%) patients were successfully managed conservatively while the remaining 43 (60%) underwent surgery. The intraoperative findings were in concordance with the preoperative computed tomography scan in 76% of cases. CONCLUSION Adhesions remain prevalent despite the absence of previous abdominal surgery. Non-operative management is feasible for SBO in a virgin abdomen. Computed tomography scan can be a useful adjunct in discerning patients who may be treated non-operatively by elucidating the underlying cause of obstruction.
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35
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Validation of the anatomic severity score developed by the American Association for the Surgery of Trauma in small bowel obstruction. J Surg Res 2016; 204:428-434. [DOI: 10.1016/j.jss.2016.04.076] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 03/14/2016] [Accepted: 04/29/2016] [Indexed: 12/31/2022]
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36
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Csendes J. A, Pereira P, D. MZ, Arratia I, Gonzalez J, Carriel F. Tratamiento médico o quirúrgico de la obstrucción intestinal alta. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.rchic.2014.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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37
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Higashizono K, Aikou S, Yagi K, Mori K, Yamashita H, Nomura S, Seto Y. Early endoscopic management for early bowel obstruction after gastrectomy: a case report. Surg Case Rep 2016; 2:35. [PMID: 27072943 PMCID: PMC4829564 DOI: 10.1186/s40792-016-0164-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 04/07/2016] [Indexed: 11/29/2022] Open
Abstract
Background Early bowel obstruction is not a rare complication of gastrectomy, and it may require re-operation in some cases. Case presentation We report the case of a 71-year-old woman who underwent a total gastrectomy with Roux-en-Y reconstruction for a massive gastrointestinal stromal tumor. Postoperatively, she was making good progress and started consuming meals on postoperative day 3. However, on postoperative day 10, she complained of upper abdominal discomfort and nausea. Blood tests showed a mild inflammatory reaction. An upper gastrointestinal series showed obstruction of the elevated jejunum. An abdominal computed tomography scan suggested upper bowel obstruction. Endoscopic observation and repositioning was selected as an effective approach for treatment considering the patient’s clinical condition and background. Upper gastrointestinal endoscopy showed kinking of the elevated jejunum, easy passage through to the anal intestine, and no evidence of mucosal edema, stenosis of the Roux-en-Y anastomosis, bowel ischemia, or necrosis. After endoscopic repositioning, upper gastrointestinal series showed good passage of the jejunum and no evidence of bowel obstruction. At the 6-month follow-up examination, the patient was in good condition and had no complaints. Conclusion We concluded that early endoscopic management should be the effective procedure considered for diagnosis and treatment of early bowel obstruction after gastrectomy in some cases.
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Affiliation(s)
- K Higashizono
- Department of Gastrointestinal Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - S Aikou
- Department of Gastrointestinal Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - K Yagi
- Department of Gastrointestinal Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - K Mori
- Department of Gastrointestinal Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - H Yamashita
- Department of Gastrointestinal Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - S Nomura
- Department of Gastrointestinal Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Y Seto
- Department of Gastrointestinal Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Kothari AN, Liles JL, Holmes CJ, Zapf MAC, Blackwell RH, Kliethermes S, Kuo PC, Luchette FA. "Right place at the right time" impacts outcomes for acute intestinal obstruction. Surgery 2015; 158:1116-25; discussion 1125-7. [PMID: 26243347 DOI: 10.1016/j.surg.2015.06.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 06/07/2015] [Accepted: 06/24/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND The purpose of this study was to measure how the duration of nonoperative intervention for intestinal obstruction impacted patient outcomes and whether hospital characteristics influenced the timing of operative intervention. METHODS The State Inpatient Database (Florida) of the Health Care Utilization Project and the Annual Survey database of the American Hospital Association were linked from 2006 to 2011. Included were patients ≥18 years of age with a primary diagnosis of intestinal obstruction. Patient factors included age, sex, socioeconomic factors, and comorbid conditions. RESULTS A total of 116,195 patients met our inclusion criteria, and 43,079 underwent operative intervention (37.1%). Patients who required operative correction of the intestinal obstruction after the fifth day of hospitalization, compared with patients who underwent an operation on the day of admission, had increases in mortality (6.1% vs 1.8%, P < .001), complication rates (15.4% vs 4.0%, P < .001), and postoperative hospital stay (9 vs 5 days, P < .001). Patients cared for at a large teaching facility (with surgery residents) had increased odds of early operative intervention by 23% (odds ratio 1.23, [1.20-1.28]), whereas patients at low-volume hospitals had decreased odds of early intervention (odds ratio 0.88, [0.73-0.91]). CONCLUSION Initial nonoperative treatment in patients with uncomplicated intestinal obstruction is an important strategy, but the odds of having an adverse event increase as intestinal obstruction is delayed. Importantly, the presence of surgery residents and increasing bed size are hospital characteristics associated with earlier operative intervention, suggesting a quality benefit for care at large teaching hospitals.
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Affiliation(s)
- Anai N Kothari
- Department of Surgery, Loyola University Medical Center, Maywood, IL; One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL
| | - Jordan L Liles
- Loyola Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Casey J Holmes
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Matthew A C Zapf
- One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL; Loyola Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Robert H Blackwell
- One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL; Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Stephanie Kliethermes
- One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL; Department of Public Health Sciences, Loyola University Chicago, Maywood, IL
| | - Paul C Kuo
- Department of Surgery, Loyola University Medical Center, Maywood, IL; One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL
| | - Fred A Luchette
- Department of Surgery, Loyola University Medical Center, Maywood, IL; One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines Jr. Veterans Administration Medical Center, Hines, IL.
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A protocol for the management of adhesive small bowel obstruction. J Trauma Acute Care Surg 2015; 78:13-9; discussion 19-21. [PMID: 25539198 DOI: 10.1097/ta.0000000000000491] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Differentiating between partial adhesive small bowel obstruction (aSBO) likely to resolve with medical management and complete obstruction requiring operative intervention remains elusive. We implemented a standardized protocol for the management of aSBO and reviewed our experience retrospectively. METHODS Patients with symptoms of aSBO were admitted for intravenous fluid resuscitation, bowel rest, nasogastric tube decompression, and abdominal examinations every 4 hours. Laboratory values and a computed tomography scan of the abdomen and pelvis with intravenous contrast were obtained. Patients with peritonitis or computed tomography scan findings suggesting bowel compromise were taken to the operating room for exploration following resuscitation. All other patients received 80 mL of Gastroview (GV) and 40 mL of sterile water via nasogastric tube. Abdominal plain films were obtained at 4, 8, 12, and 24 hours. If contrast did not reach the colon within 24 hours, then operative intervention was performed. RESULTS Over 1 year, 91 patients were admitted with aSBO. Sixty-three patients received GV, of whom 51% underwent surgery. Twenty-four patients went directly to the operating room because of clinical or imaging findings suggesting bowel ischemia. Average time to surgery was within 1 day for the no-GV group and 2 days for the GV group. Patients passing GV to the colon within 5 hours of administration had a 90% rate of resolution of obstruction. There was a direct relationship between the duration of time before passing GV to the colon and hospital length of stay (HLOS) (r = 0.459). Patients who received GV and did not require surgery had lower HLOS (3 days vs. 11 days, p < 0.0001). CONCLUSION The GV protocol facilitated early recognition of complete obstruction. Administration of GV had diagnostic and therapeutic value and did not increase HLOS, morbidity, or mortality. LEVEL OF EVIDENCE Therapeutic study, level V. Epidemiologic study, level V.
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Early postoperative small bowel obstruction: open vs laparoscopic. Am J Surg 2014; 209:385-90. [PMID: 25457244 DOI: 10.1016/j.amjsurg.2014.07.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 06/28/2014] [Accepted: 07/15/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND The window for safe reoperation in early postoperative (<6 weeks) small bowel obstruction (ESBO) is short and intimately dependent on elapsed time from the initial operation. Laparoscopic procedures create fewer inflammatory changes than open laparotomies. We hypothesize that it is safer to reoperate for ESBO after laparoscopic procedures than open. METHODS Review of patients who underwent re-exploration for ESBO from 2003 to 2009 was performed. Based on the initial operation, patients were classified as "open" or "laparoscopic." The Revised Accordion Severity Grading System was used to define complications as minor (1 to 2) or severe (3 to 6). RESULTS There were 189 patients identified (age 55 years, 48% male): 130 open and 59 laparoscopic. Adhesive disease was more common (65% vs 42%, P < .01), while strictures were less frequent (5% vs 14% P = .03), in the open group. The open group had a greater rate of malignancy, days to re-exploration, and severity of complications. There was no difference in the rates of minor complications, enterotomy, and mortality. ESBO after laparoscopic surgery was more commonly caused by a focal source (85% vs 63%). Eighty-three patients (64 open, 19 laparoscopic) underwent re-exploration at or beyond 14 days. Within this subgroup, there were more severe complications (25% vs 5%) after open procedures with equivalent mortality (4% vs 0%). CONCLUSIONS Laparoscopic approaches confer a lower rate of adhesive disease and severity of complications in early SBO as compared with open surgery even if performed after 2 weeks of index procedure.
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Beardsley C, Furtado R, Mosse C, Gananadha S, Fergusson J, Jeans P, Beenen E. Small bowel obstruction in the virgin abdomen: the need for a mandatory laparotomy explored. Am J Surg 2014; 208:243-8. [DOI: 10.1016/j.amjsurg.2013.09.034] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 08/30/2013] [Accepted: 09/01/2013] [Indexed: 12/31/2022]
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Si-jun-zi decoction treatment promotes the restoration of intestinal function after obstruction by regulating intestinal homeostasis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2014; 2014:928579. [PMID: 24876882 PMCID: PMC4020469 DOI: 10.1155/2014/928579] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 03/23/2014] [Accepted: 03/23/2014] [Indexed: 11/17/2022]
Abstract
Intestinal obstruction is a common disease requiring abdominal surgery with significant morbidity and mortality. Currently, an effective medical treatment for obstruction, other than surgical resection or decompression, does not exist. Si-Jun-Zi Decoction is a famous Chinese medicine used to replenish qi and invigorate the functions of the spleen. Modern pharmacological studies show that this prescription can improve gastrointestinal function and strengthen immune function. In this study, we investigated the effects of a famous Chinese herbal formula, Si-Jun-Zi Decoction, on the restoration of intestinal function after the relief of obstruction in a rabbit model. We found that Si-Jun-Zi Decoction could reduce intestinal mucosal injury while promoting the recovery of the small intestine. Further, Si-Jun-Zi Decoction could regulate the intestinal immune system. Our results suggest that Si-Jun-Zi Decoction promotes the restoration of intestinal function after obstruction by regulating intestinal homeostasis. Our observations indicate that Si-Jun-Zi Decoction is potentially a therapeutic drug for intestinal obstruction.
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Abstract
For patients with small bowel and colonic perforations, a definitive diagnosis of the cause of perforation is not necessary before operation. Bowel obstruction and inflammatory bowel disease are the most common causes of nontraumatic intestinal perforations in industrialized countries, whereas infectious causes of intestinal perforations are more common in developing countries. Treatment of small bowel and colonic perforations generally includes intravenous antibiotics and fluid resuscitation, but the specific management of the bowel depends on the underlying cause of the perforation.
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Affiliation(s)
- Carlos V R Brown
- University Medical Center Brackenridge, 601 East 15th Street, Austin, TX 78701, USA.
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Role of gastrografin challenge in early postoperative small bowel obstruction. J Gastrointest Surg 2014; 18:363-8. [PMID: 24165871 DOI: 10.1007/s11605-013-2347-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 08/29/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Early small bowel obstruction following abdominal surgery presents a diagnostic and therapeutic challenge. Abdominal imaging using Gastrografin has been shown to have diagnostic and therapeutic properties when used in the setting of small bowel obstruction outside the early postoperative period (>6 weeks). We hypothesize that a GG challenge will reduce need for re-exploration. METHODS Patients with early small bowel obstruction who underwent a Gastrografin challenge between 2010 and 2012 were case controlled, based on age ±5 years, sex, and operative approach to an equal number of patients that did not receive the challenge. RESULTS One hundred sixteen patients received a Gastrografin challenge. There were 87 males in each group with an average age of 62 years. A laparoscopic approach in the index operation was done equally between groups (18 vs. 18 %). There was no difference between groups in operative re-exploration rates (14 vs. 10 %); however, hospital duration of stay was greater in patients who received Gastrografin challenge (17 vs. 13 days). Two in hospital deaths occurred, one in each group, both of infectious complications. CONCLUSION Use of the Gastrografin challenge in the immediate postoperative period appeared to be safe. There was no difference, however, in the rate of re-exploration between groups.
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Di Saverio S, Coccolini F, Galati M, Smerieri N, Biffl WL, Ansaloni L, Tugnoli G, Velmahos GC, Sartelli M, Bendinelli C, Fraga GP, Kelly MD, Moore FA, Mandalà V, Mandalà S, Masetti M, Jovine E, Pinna AD, Peitzman AB, Leppaniemi A, Sugarbaker PH, Goor HV, Moore EE, Jeekel J, Catena F. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg 2013; 8:42. [PMID: 24112637 PMCID: PMC4124851 DOI: 10.1186/1749-7922-8-42] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 09/23/2013] [Indexed: 12/19/2022] Open
Abstract
Background In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy. Recommendations In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay. NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended. Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery. Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained. Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery. Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.
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Affiliation(s)
- Salomone Di Saverio
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | | | - Marica Galati
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Nazareno Smerieri
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Walter L Biffl
- Department of Surgery, Denver Health, University of Colorado Health Sciences Denver, Denver Health Medical Center, 777 Bannock Street, Denver CO 80204, USA
| | - Luca Ansaloni
- General Surgery I, Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - Gregorio Tugnoli
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - George C Velmahos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Cino Bendinelli
- Department of Surgery, John Hunter Hospital and University of Newcastle, Locke Bag 1 Hunter Region Maile Centre, Newcastle, NSW 2310, Australia
| | | | - Michael D Kelly
- Upper GI Unit, Department of Surgery, Frenchay Hospital, North Bristol, NHS Trust, Bristol, UK
| | - Frederick A Moore
- Department of Surgery, University of Florida, Gainesville, FL 32610-0254, USA
| | - Vincenzo Mandalà
- Department of General and Emergency Surgery, Associated Hospitals "Villa Sofia - Cervello", Palermo, Italy
| | - Stefano Mandalà
- Department of General and Emergency Surgery, Associated Hospitals "Villa Sofia - Cervello", Palermo, Italy
| | - Michele Masetti
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Elio Jovine
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Antonio D Pinna
- Emergency Surgery Unit, Department of General and Multivisceral Transplant Surgery, S Orsola Malpighi University Hospital, Bologna, Italy
| | - Andrew B Peitzman
- Division of General Surgery, University of Pittsburgh Physicians, Pittsburgh 15213 PA, USA
| | - Ari Leppaniemi
- Emergency Surgery, Department of Abdominal Surgery, Meilahti Hospital, University of Helsinki, Haartmaninkatu 4, 340, Helsinki FIN-00029 HUS, Finland
| | - Paul H Sugarbaker
- Washington Cancer Institute, Washington Hospital Center, Washington, 20010 DC, USA
| | - Harry Van Goor
- Department of Surgery, Radboud University Nijmegen Medical Centre, P.O. Box 9101 6500 HB, Nijmegen, The Netherlands
| | - Ernest E Moore
- Department of Surgery, Denver Health, University of Colorado Health Sciences Denver, Denver Health Medical Center, 777 Bannock Street, Denver CO 80204, USA
| | - Johannes Jeekel
- Department of Surgery, Erasmus University Medical Center, PO Box 2040 3000 CA, Rotterdam, The Netherlands
| | - Fausto Catena
- Emergency Surgery Unit, Department of General and Multivisceral Transplant Surgery, S Orsola Malpighi University Hospital, Bologna, Italy.,Department of Emergency and Trauma Surgery, Maggiore Hospital of Parma, Parma, Italy
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Khasawneh MA, Eiken PW, Srvantstyan B, Bannon MP, Zielinski MD. Use of the Gastrografin challenge in patients with a history of abdominal or pelvic malignancy. Surgery 2013; 154:769-75; discussion 775-6. [DOI: 10.1016/j.surg.2013.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 07/02/2013] [Indexed: 12/14/2022]
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Early Operation Is Associated With a Survival Benefit for Patients With Adhesive Bowel Obstruction. Ann Surg 2013; 258:459-65. [DOI: 10.1097/sla.0b013e3182a1b100] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Goussous N, Eiken PW, Bannon MP, Zielinski MD. Enhancement of a small bowel obstruction model using the gastrografin® challenge test. J Gastrointest Surg 2013; 17:110-6; discussion p.116-7. [PMID: 22923211 DOI: 10.1007/s11605-012-2011-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 08/14/2012] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Naeem Goussous
- Department of General Surgery, Mayo Clinic, Rochester, MN 55902, USA
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