Non-operative management for small bowel obstruction in a virgin abdomen: a systematic review

Radiomics-based machine learning model for diagnosing internal abdominal hernias: a retrospective study

Intraperitoneal hernia is an acute abdominal disease, with complex imaging features and variable clinical manifestations that challenge surgeons and emergency physicians in early disease assessment and streamlined diagnosis and treatment procedures. We retrospectively included patients with internal abdominal hernia between January 2021 and June 2024. Eight machine learning models were constructed, and the classifier with the best performance was selected based on comparative evaluation. The performance of each model was assessed using the area under the curve (AUC), accuracy, and specificity to determine the optimal radiomics-based predictive algorithm. A total of 107 radiomics features were extracted, revealing distinct features between herniated and normal intestines. A predictive model for internal abdominal hernias was constructed based on a machine learning algorithm incorporating 7 different features. The Random Forest model demonstrated superior performance, achieving an AUC of 1, accuracy of 90%, sensitivity of 80%, and specificity of 100% in validation set. Radiomics analysis of internal abdominal hernias provides substantial data support for early disease diagnosis, but it is still a need for validation with a larger sample size in the future.

Changing the Paradigm for Managing Pediatric Nonadhesive Small Bowel Obstructions-Should We Operate?

INTRODUCTION

Growing evidence supports the success of nonoperative management (NOM) for pediatric adhesive small bowel obstruction (A-SBO). However, there is concern that patients with nonadhesive SBO (NA-SBO) will have repeat episodes of SBO if not treated with surgery upfront. We examined whether NOM of NA-SBO at initial presentation was associated with increased risk of recurrent SBO.

METHODS

A single-center observational study was performed using Current Procedural Terminology/International Classification of Disease (ICD) codes and chart review. NA-SBO was defined as SBO in a patient with no history of SBOs, prior abdominal surgeries, or congenital gastrointestinal abnormalities known to cause SBO. We excluded patients with incarcerated hernias and tumors. The independent variable was surgical treatment at initial SBO admission and primary outcome was SBO recurrence within 1 y.

RESULTS

Our cohort included 97 patients, with 30 patients (31%) undergoing surgery at initial NA-SBO admission. There was no difference in rates of recurrent SBO within 1 y when comparing the operative versus nonoperative management groups (6.7% versus 8.9%, P = 0.70). Among patients who recurred, there was no difference in need for surgical intervention (2/6 versus 0/2, P = 0.34). None of the operations for recurrence were urgent or emergent. Patients managed nonoperatively had a shorter median length of stay (2 versus 7 d, P < 0.001) and did not have significantly more emergency room visits (10.4% versus 6.7%, P = 0.55).

CONCLUSIONS

NOM of NA-SBO was not associated with increased rates of SBO recurrence, and NOM did not lead to increased morbidity. Surgeons should consider NOM in stable pediatric patients who present with NA-SBO.

Band adhesions in a virgin abdomen: A case report

INTRODUCTION

Small bowel obstruction secondary to adhesions in a virgin abdomen is encountered very rarely. Its rarity may cause a delay in diagnosis that can lead to complications among which is sepsis and death. In contrast, On-time diagnosis constitutes one of many pillars of the best outcome for the patient.

CASE PRESENTATION

We present a case of a 46-year-old female exhibiting symptoms of small bowel obstruction that persisted for five days. Her previous surgical history was negative. Upon testing, we found a neutrophilic leukocytosis and an abdominal x-ray revealed dilated bowel loops with multiple air-fluid levels and no air under the diaphragm with an increased pulse rate and respiratory rate. An emergency exploratory laparotomy definitively identified congenital band adhesions as the root cause of the obstruction.

DISCUSSION

Abdominal x-ray is the starting investigation in rural health facilities of Low and Middle Income Countries (LMICs), but lacks the ability to detect complications such as strangulation and ischemia as can the multidetector Computed Tomography scan and the Magnetic Resonance Imaging. A non-resolving small bowel obstruction or the one associated with peritonitis or bowel ischemia should undergo a surgical intervention.

CONCLUSION

A negative surgical history should not annihilate the suspicion of band adhesions in small bowel obstruction. Early diagnostic imaging is helpful. When this is not possible, a laparotomy should be done if clinically indicated. The patient had an uneventful recovery.

Don't Let the Sun Rise on Small Bowel Obstruction Without Surgical Consultation-Redefining Nonoperative Management Pathways

Introduction: Small bowel obstruction (SBO) is a common cause of hospital admission leading to resource utilization. The majority of these patients require non-operative management (NOM) which can lead to increased length of stay (LOS), readmissions, resource utilization, and throughput delays. Early surgical consultation (SC) for SBO may improve efficiency and outcomes. Methods: We implemented an institution-wide intervention (INT) to encourage early SC (<1 day of diagnosis) for SBO patients in July 2022. A retrospective analysis was performed on all patients with SBO requiring NOM from January 2021 to June 2023, categorized into pre- and post-INT groups. The primary outcome was the number of SC's and secondary outcomes were early SC (<1 day of diagnosis), utilization of SBFT, LOS, 30-day readmission, and costs of admission. Results: A total of 670 patients were included, 438 in the pre-INT and 232 in the post-INT group. Overall, SBFT utilization was significantly higher in cases with SC (17.2% vs 41.4%, P < .001). Post-INT patients were more likely to receive SC (94.0% vs 83.3%, P < .001) and increased SBFT utilization (47.0% vs 33.6%, P = .001). Additionally, early SC improved significantly in the post-INT group (74.3% vs 65.7%, P = .03). There was no difference in LOS between groups (4.0 vs 3.8 days, P = .48). There was a trend toward decreased readmission rates in the INT group at 30 days (7.3% vs 11.0%, P = .13) and reduced direct costs in the INT group (US$/admission = 8467 vs 8708, P = .1). Conclusion: Hospital-wide interventions to increase early surgical involvement proved effective by improving early SC, increased SBFT utilization, and showed a trend towards decreased readmission rates and direct costs.

"Bezoar Egg"-A Rare Cause of Small Bowel Obstruction

Small bowel obstruction is a frequent medical condition with various causes, the most common being postoperative adhesions, volvulus, intussusception, hernias, and tumors. A bezoar-induced blockage of the small intestine is a rare condition that accounts for approximately 4% of all small bowel obstruction cases. Herein, we present the case report of a 71-year-old patient with diffuse abdominal pain caused by a small bowel obstruction due to a calcified bezoar (bezoar egg) resulting from a post-radiation intestinal stricture. The patient underwent a small bowel excision with the extraction of the bezoar, after which a full recovery was made.

Small bowel obstruction caused by a mango phytobezoar within a Meckel's diverticulum

A fit and well gentleman in his 40s presented with vomiting and obstipation. His only relevant history being recent ingestion of a large quantity of mangoes. A computer tomography demonstrated a small bowel obstruction with a transition point in the right iliac fossa, but no other pathological findings. After a short period of non-operative management he proceeded to surgery, where a phytobezoar was identified at a Meckel's diverticulum causing a pantaloon shaped intra-luminal obstruction. A small bowel resection and primary anastomosis was performed and the patient had an uncomplicated post-operative course. Meckel's diverticuli are a relatively common phenomenon and may pre-dispose to bowel obstructions through a number of different mechanisms. This unusual case highlights the importance of considering this as a differential, and one that will likely require timely operative intervention.

The Angers CT Score is a Risk Factor for the Failure of the Conservative Management of Adhesive Small Bowel Obstruction: A Prospective Observational Multicentric Study

BACKGROUND

Identifying the 30% of adhesive small bowel obstructions (aSBO) for which conservative management will require surgery is essential. The association between the previously described radiological score and failure of the conservative management of aSBO remains to be confirmed in a large prospective multicentric cohort. Our aim was to assess the risk factors of failure of the conservative management of aSBO considering the radiological score.

MATERIAL AND METHODS

This prospective observational study took place in 15 French centers over 3 months. Consecutive patients experiencing aSBO with no early surgery were included. The six radiological features from the Angers radiological computed tomography (CT) score were noted (beak sign, closed loop, focal or diffuse intraperitoneal liquid, focal or diffuse mesenteric haziness, focal or diffuse mesenteric liquid, and diameter of the most dilated small bowel loop > 40 mm).

RESULTS

Two hundred and seventy nine patients with aSBO were screened. Sixty patients (21.5%) underwent early surgery, and 219 (78.5%) had primary conservative management. In the end, 218 patients were included in the analysis of the risk factors for conservative treatment failure. Among them, 162 (74.3%) had had successful management while for 56 (25.7%) management had failed. In multivariate analysis, a history of surgery was not a significant risk factor for the failure of conservative treatment (OR = 0.11; 95%CI = 0-1.23). A previous episode of aSBO was protective against the failure of conservative treatment (OR = 0.36; 95%CI = 0.15-0.85) and an Angers CT score ≥ 5 as the only individual risk factor (OR = 2.39; 95%CI = 1.01-5.69).

CONCLUSION

The radiological score of aSBO is a promising tool in improving the management of aSBO patients. A first episode of aSBO and/or a radiological score ≥5 should lead physicians to consider early surgical management.

Small Bowel Obstruction in Patients without Prior Abdominal Surgery: To Operate or Not?

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%.

Ileal Tubulo-Villous Adenoma Causing Small Bowel Obstruction in a Virgin Abdomen

Small bowel obstructions (SBO) are a common surgical problem accounting for up half of all emergency laparotomies in the United States. SBO in the virgin abdomen (SBO-VA) presents surgeons with a unique predicament as historical teaching has mandated operative exploration in these situations due to their association with more sinister etiologies. More recent research has demonstrated that this may not be the case, with adhesive disease comprising the majority of SBO-VA. Small bowel neoplasms however comprise a considerable portion of SBO-VA. Small bowel tumors comprise around 0.5%-2% of all gastrointestinal tumors, with adenomas being the most common type of benign small bowel tumor. These lesions are most commonly encountered in the duodenum, typically involving the peri-ampullary region, Their incidence decreases with descent down the gastrointestinal tract, and are least commonly found in the ileum. Ileal adenomas have been increasingly described in the literature with the rise of advanced imaging and endoscopic capabilities. The vast majority of these lesions remain asymptomatic; however, they have been reported to undergo malignant transformation resulting in obstruction and intussusception. Small bowel obstruction due to ileal adenomas in the absence of malignancy is exceedingly rare, with only one previously reported case in the literature. We describe a case of an SBO-VA secondary to ileal stricture caused by a tubulo-villous adenoma. We then discuss the topics of SBO and SBO-VA, specifically regarding their etiology and historical and modern management, with a particular focus on the diagnosis and management of small bowel neoplasms, specifically small bowel adenomas.