Small Bowel Obstruction

Doing Less Later: Seniorization of General Surgery Resident Operative Experience in the Entrustable Professional Activities at Veterans Affairs Hospitals

OBJECTIVE

Identify changes in general surgery resident autonomy and resident postgraduate year (PGY) level in Entrustable Professional Activity (EPA) cases over time.

DESIGN

Retrospective cohort study.

SETTING

United States Veterans Affairs (VA) hospital system, 2004 to 2020.

PARTICIPANTS

All patients undergoing operations in any of the 12 general surgery EPAs with identifiable operative components captured by the VA Surgical Quality Improvement Project database from 2004 to 2020.

RESULTS

452,549 cases were identified. Between 2004 and 2020, there was a 61.4% decrease in resident-performed cases and a 14.3% decrease in attending-assisted cases, with a concomitant 51.8% increase in attending-performed cases. All EPAs experienced a statistically significant decrease in resident autonomy over the study period, and a net transfer of cases from resident-performed to attending-performed. About 7 of 12 EPAs had significant increases in the resident PGY level of attending-assisted cases over the study period: abdominal wall hernia, benign/malignant breast, benign/malignant colon, cutaneous/subcutaneous neoplasm, gallbladder disease, inguinal hernia, and soft tissue infection. About 3 EPAs had significant increases in the resident PGY of resident-performed cases: abdominal wall hernia, benign/malignant breast, and inguinal hernia. Many of these changes represented seniorization of the operative experience by 3 to 12 months.

CONCLUSIONS

There has been a continual decrease in resident operative autonomy across all general surgery EPAs at the VA. Furthermore, many EPA cases have shifted to more senior residents over time, delaying or deferring autonomous completion of these cases during training. Although these data were drawn from the VA system, the results likely reflect a continued decrease in autonomy for resident surgeons in other settings as well. As general surgery adapts to a competency-based educational model, action is needed to stabilize these changes for sustainable graduate surgical education.

Noncalcified Gallstone Ileus in Computed Tomography (CT) Abdomen and Pelvis With Contrast

Gallstone ileus is a rare but serious complication of chronic cholecystitis, causing mechanical small bowel obstruction. Contrast-enhanced computed tomography (CT) plays a key role in radiological diagnosis. The classic findings are known as Rigler's triad, comprised of pneumobilia, small bowel obstruction, and calcified gallstones. We report a unique case of a 74-year-old female patient who presented with hallmark clinical features of bowel obstruction. CT revealed bowel obstruction and pneumobilia but did not show calcified gallstones, deviating from the usual Rigler's triad. Following midline laparotomy, a noncalcified gallstone was confirmed causing bowel obstruction. This case underscores the need to consider gallstone ileus in small bowel obstruction even in rare cases where conventional CT findings are not present, alongside the value of comprehensive radiological analysis and maintaining a high degree of clinical suspicion. Timely recognition of such atypical cases is vital for effective surgical treatment and better patient outcomes.

Laparoscopic application of sodium hyaluronate-carboxymethylcellulose barrier in abdominopelvic surgery: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Systematic Review Protocols-compliant systematic review and meta-analysis

BACKGROUND

We aimed to evaluate the incidence of postoperative adhesion formation and adhesion-related consequences (eg, bowel obstruction) after placement of a sodium hyaluronate-carboxymethylcellulose adhesion barrier after laparoscopic abdominopelvic surgery.

METHODS

In this systematic review and meta-analysis, we searched the Medical Literature Analysis and Retrieval System Online and Embase via Ovid, Cochrane Central Register of Controlled Trials, ScienceDirect, BIOSIS Previews, Cumulative Index to Nursing and Allied Health Literature, and Clinical Trial Registries. A manual search (eg, Google Scholar and professional association websites) was also conducted to supplement the electronic database results. Two reviewers independently identified relevant studies based on inclusion and exclusion criteria and extracted data.

RESULTS

A total of 28 studies were included in the systematic qualitative review. Three of the 28 studies included had comparable outcome measures, interventions, and control groups, allowing the pooling of study data. A total of 938 patients (490 patients in the sodium hyaluronate-carboxymethylcellulose barrier group and 448 in the no adhesion barrier group) from these 3 studies were included in the meta-analyses, which found the incidence of bowel obstruction was significantly lower (65% risk reduction) in the sodium hyaluronate-carboxymethylcellulose barrier group compared with the control group (relative risk = 0.35; 95% confidence interval, 0.19-0.63; P = .005) with extremely low heterogeneity between studies (I2 = 0; P = .41). The placement of sodium hyaluronate-carboxymethylcellulose barrier laparoscopically did not create new safety signals nor did it increase the incidence of adverse events.

CONCLUSION

Our meta-analysis found that laparoscopic application of a sodium hyaluronate-carboxymethylcellulose barrier in abdominopelvic surgery reduces the risk of bowel obstruction where applied during the early postoperative phase.

Leveraging Dual-Energy Computed Tomography to Improve Emergency Radiology Practice

Dual-energy computed tomography affords emergency radiologists with important tools to aid in the detection and discrimination of commonly encountered ED pathologies. In doing so, it can increase the speed of diagnosis and diagnostic certainty while sparing patients potentially unnecessary downsteam workups and radiation exposure. This article demonstrates these clinical benefits through a case-based approach.

Small bowel obstruction secondary to phytobezoar in a patient with myotonic dystrophy

A male patient in his 30s, with myotonic dystrophy (DM), presented to the emergency department with abdominal pain and vomiting. CT imaging revealed a soft tissue lesion in the terminal ileum causing small bowel obstruction (SBO). The patient underwent diagnostic laparoscopy which allowed identification and removal of the obstructing lesion. This was in the form of an intact, undigested potato, a phytobezoar. Bezoars are collections of undigested material found in the gastrointestinal (GI) tract, a phytobezoar is composed of plant material and is the most common form of bezoar. DM is a multisystem disorder characterised by skeletal muscle weakness, however it often presents with GI symptoms and the muscles of mastication are often affected. DM is a known risk factor for bezoar formation and should be considered as an important differential in DM patients presenting with SBO.

"Choice of surgical approach for the treatment of acute small bowel obstruction: A retrospective analysis from a high-volume single center in Milan, Northern Italy"

Background

Acute small bowel obstruction (aSBO) is the most common cause (76%) of acute intestinal obstruction. Laparoscopy use is still controversial in aSBO and indications not yet clearly defined. The aim of this study was to demonstrate the effectiveness and safety of a laparoscopic approach in aSBO by using specific pre-operative criteria for appropriate patient selection.

Methods

We retrospectively analyzed medical records of patients accepted at the Emergency Department for aSBO between January 2016 and March 2021 and performed a comparative analysis between types of treatment, considering demographics, clinical and radiological presentation, non-operative vs. operative management, intraoperative outcome, and postoperative course. We used a logistic regression to identify the variables related to surgical approach and built a predictive score upon the multivariable predictive model: the "SABO score".

Results

198 patients were included in the study, of which 145 underwent surgery and 43 were successfully treated laparoscopically. Age and comorbidities were associated with open surgery (OR 3.2, 95% CI: 1.4-7.2, p = 0.006 and OR 2.7, 95% CI: 1.1-6.5, p = 0.023). A SABO score ≥ 0 identified an open approach with a sensitivity of 75.4% and a specificity of 69.8%.

Conclusions

Laparoscopy is growing in importance even in emergency settings. Our analysis suggests that a laparoscopic approach can be safe and feasible in aSBO management. Correct patient selection appears to be the key for a successful minimally invasive approach. SABO score therefore could be helpful in choosing the correct surgical strategy for patients with aSBO.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.

Diagnosis and surgical management strategy for pediatric small bowel obstruction: Experience from a single medical center

Identifying Bowel strangulation and the approach and timing of surgical intervention for pediatric SBO are still uncertain. In this study, 75 consecutive pediatric patients with surgically confirmed SBO were retrospectively reviewed. The patients were divided into group 1 (n = 48) and group 2 (n = 27) according to the presence of reversible or irreversible bowel ischemia, which was analyzed based on the degree of ischemia at the time of operation. The results demonstrated that the proportion of patients with no prior abdominopelvic surgery was higher, the serum albumin level was lower, and the proportion of patients in which ascites were detected by ultrasonography was higher in group 2 than that in group 1. The serum albumin level was negatively correlated with ultrasonographic findings of the fluid sonolucent area in group 2. There were significant differences in the choice of surgical approach between group 1 and group 2. A symptom duration of >48 h was associated with an increased bowel resection rate. The mean length of hospital stay was shorter in group 1 than that in group 2. In conclusion, immediate surgical intervention should be considered in patients with a symptom duration of >48 h or the presence of free ascites between dilated small bowel loops on ultrasonography. Laparoscopic exploration is recommended as first-line treatment in patients with stable status.