A multidisciplinary approach to diagnosis and management of bowel obstruction

Use of a 5-Item Modified Frailty Index for Assessing Outcomes After Hartmann's Reversal: An ACS-NSQIP Study

BACKGROUND

Half of all patients with an end colostomy after sigmoid colectomy (Hartmann's procedure) never undergo Hartmann's reversal, frequently secondary to frailty. This retrospective cohort study evaluates the utility of a five-item modified frailty index (mFI-5) in predicting post-operative outcomes after Hartmann's reversal.

METHODS

The National Surgery Quality Improvement Program (NSQIP) database captured patients with elective Hartmann's reversals from 2011 to 2020. Clinical covariates were evaluated with univariate analysis and modified Poisson regression to determine association with overall morbidity, overall mortality, and extended length of stay (eLOS) when categorized by mFI-5 score.

RESULTS

15,172 patients underwent elective Hartmann's reversal (91.6% open and 8.4% laparoscopic). Patients were grouped by mFI-5 score (0: 48.7%, 1: 38.2%, ≥ 2: 13.1%). Adjusted multivariable analysis showed frail patients (mFI-5≥2) had increased overall mortality (OR 2.23, 95% CI 1.21-4.11), morbidity (OR 1.23, 95% CI 1.12-1.35), and eLOS (OR 1.12, 95% 1.02-1.23). Among frail patients, a laparoscopic approach was associated with decreased overall morbidity (OR .64, 95% CI 0.56-.73) and decreased eLOS (OR .46, 95% CI 0.39-.54) when compared to open approach.

DISCUSSION

An mFI-5 of ≥2 was associated with greater morbidity, mortality, and eLOS following Hartmann's reversal. However, there were no mortality or eLOS differences in patients with an mFI-5 of 1 and only a 14% increase in any morbidity, making these patients potentially good candidates for Hartmann's reversal. Furthermore, laparoscopic surgery was associated with a protective effect for overall morbidity and eLOS, potentially mitigating some of the risk associated with higher frailty scores.

Malignant Acute Colonic Obstruction: Multidisciplinary Approach for Endoscopic Management

Patients presenting with acute colonic obstruction are usually evaluated in the emergency department and multiple specialties are involved in the patients' management. Pre-treatment evaluation is essential in order to establish the correct endoscopic indication for stent implantation. Contrast-enhanced imaging could allow the exclusion of benign causes of colonic obstruction and evaluation of the length of malignant stricture. Endoscopic stenting is the gold standard of treatment for palliative indications whereas there are still concerns about its use as a bridge to surgery. Different meta-analyses showed that stenting as a bridge to surgery improves short-term surgical outcomes but has no role in improving long-term outcomes. Multidisciplinary evaluation is also essential in patients that may be started on or are currently receiving antiangiogenic agents because endoscopic stenting may increase the risk of perforation. Evidence in the literature is weak and based on retrospective data. Here we report on how to correctly evaluate a patient with acute colonic malignant obstruction in collaboration with other essential specialists including a radiologist, surgeon and oncologist, and how to optimize the technique of endoscopic stenting.

Ultrasound of Small Bowel Obstruction: A Pictorial Review

Small bowel obstruction (SBO) is a common condition requiring urgent attention that may involve surgical treatment. Imaging is essential for the diagnosis and characterization of SBO because the clinical presentation and results of laboratory tests may be nonspecific. Ultrasound is an excellent initial imaging modality for assisting physicians in the rapid and accurate diagnosis of a variety of pathologies to expedite management. In the case of SBO diagnosis, ultrasound has an overall sensitivity of 92% (95% CI: 89–95%) and specificity of 93% (95% CI: 85–97%); the aim of this review is to examine the criteria for the diagnosis of SBO by ultrasound, which can be divided into diagnostic and staging criteria. The diagnostic criteria include the presence of dilated loops and abnormal peristalsis, while the staging criteria are represented by parietal and valvulae conniventes alterations and by the presence of free extraluminal fluid. Ultrasound has reasonably high accuracy compared to computed tomography (CT) scanning and may substantially decrease the time to diagnosis; moreover, ultrasound is also widely used in the monitoring and follow-up of patients undergoing conservative treatment, allowing the assessment of loop distension and the resumption of peristalsis.

Diagnostic Accuracy of Ultrasound in the Diagnosis of Small Bowel Obstruction

INTRODUCTION

Small bowel obstruction (SBO) is a common presentation to the Emergency Department (ED). This study aimed to analyze the accuracy of ultrasound (US) in diagnosing and staging SBO.

OBJECTIVES

The main object of this study was to analyze the accuracy of ultrasound in diagnosing and staging SBO compared to CT.

METHODS

Retrospectively, stable patients with an ultrasonographic diagnosis of SBO who underwent abdominal CT immediately after US and before receiving naso-intestinal decompression, were included. US criteria for the diagnosis of SBO were related to morphological and functional findings. US diagnosis of obstruction was made if fluid-filled dilated small bowel loops were detected, peristalsis was abnormal and parietal abnormalities were present. Morphologic and functional sonographic findings were assigned to three categories: simple SBO, compensated SBO and decompensated SBO. US findings were compared with the results of CT examinations: Morphologic CT findings (divided into loop, vascular, mesenteric and peritoneal signs) allowed the classification of SBO in simple, decompensated and complicated.

RESULTS

US diagnostic accuracy rates in relation to CT results were calculated: ultrasound compared to CT imaging, had a sensitivity of 92.31% (95% CI, 74.87% to 99.05%) and a specificity of 94.12% (95% CI, 71.31% to 99.85%) in the diagnosis of SBO.

CONCLUSIONS

This study, similarly to the existing literature, suggests that ultrasound is highly accurate in the diagnosis of SBO, and that the most valuable sonographic signs are the presence of dilated bowel loops ad abnormal peristalsis.