1
|
Symer MM, Zheng X, Pua BB, Sedrakyan A, Milsom JW. Contemporary Assessment of Adhesiolysis and Resection for Adhesive Small Bowel Obstruction in the State of New York. Surg Innov 2024:15533506241240580. [PMID: 38498843 DOI: 10.1177/15533506241240580] [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: 03/20/2024]
Abstract
BACKGROUND Adhesive small bowel obstruction (aSBO) is a common surgical problem, with some advocating for a more aggressive operative approach to avoid recurrence. Contemporary outcomes in a real-world setting were examined. STUDY DESIGN A retrospective cohort study was performed using the New York Statewide Planning and Research Cooperative database to identify adults admitted with aSBO, 2016-2020. Patients were stratified by the presence of inflammatory bowel disease (IBD) and cancer history. Diagnoses usually requiring resection were excluded. Patients were categorized into four groups: non-operative, adhesiolysis, resection, and 'other' procedures. In-hospital mortality, major complications, and odds of undergoing resection were compared. RESULTS 58,976 patients were included. 50,000 (84.8%) underwent non-operative management. Adhesiolysis was the most common procedure performed (n = 4,990, 8.46%), followed by resection (n = 3,078, 5.22%). In-hospital mortality in the lysis and resection groups was 2.2% and 5.9% respectively. Non-IBD patients undergoing operation on the day of admission required intestinal resection 29.9% of the time. Adjusted odds of resection were highest for those with a prior aSBO episode (OR 1.29 95%CI 1.11-1.49), delay to operation ≥3 days (OR1.78 95%CI 1.58-1.99), and non-New York City (NYC) residents being treated at NYC hospitals (OR1.57 95%CI 1.19-2.07). CONCLUSION Adhesiolysis is currently the most common surgery for aSBO, however nearly one-third of patients will undergo a more extensive procedure, with an increased risk of mortality. Innovative therapies are needed to reduce the risk of resection.
Collapse
Affiliation(s)
- Matthew M Symer
- Department of Surgery, Division of Colon and Rectal Surgery, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Xinyan Zheng
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Bradley B Pua
- Department of Radiology, Division of Vascular and Interventional Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Art Sedrakyan
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Jeffrey W Milsom
- Department of Surgery, Division of Colon and Rectal Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
2
|
Assessing outcomes in laparoscopic vs open surgical management of adhesive small bowel obstruction. Surg Endosc 2023; 37:1376-1383. [PMID: 35587296 DOI: 10.1007/s00464-022-09314-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Small bowel obstruction is typically managed nonoperatively; however, refractory small bowel obstructions or closed loop obstructions necessitate operative intervention. Traditionally, laparotomy has long been the standard operative intervention for lysis of adhesions of small bowel obstructions. But as surgeons become more comfortable with minimally invasive techniques, laparoscopy has become a widely accepted intervention for small bowel obstructions. The objective of this study was to compare the outcomes of laparoscopy to open surgery in the operative management of small bowel obstruction. METHODS This is a retrospective analysis of operative small bowel obstruction cases at a single academic medical center from June 2016 to December 2019. Data were obtained from billing data and electronic medical record for patients with primary diagnosis of small bowel obstruction. Postoperative outcomes between the laparoscopic and open intervention groups were compared. The primary outcome was time to return of bowel function. Secondary outcomes included length of stay, 30-day mortality, 30-day readmission, VTE, and reoperation rate. RESULTS The cohort consisted of a total of 279 patients with 170 (61%) and 109 (39%) patients in the open and laparoscopic groups, respectively. Patients undergoing laparoscopic intervention had overall shorter median return of bowel function (4 vs 6 days, p = 0.001) and median length of stay (8 vs 13 days, p = 0.001). When stratifying for bowel resection, patients in the laparoscopic group had shorter return of bowel function (5.5 vs 7 days, p = 0.06) and shorter overall length of stay (10 vs 16 days, p < 0.002). Patients in the laparoscopic group who did not undergo bowel resection had an overall shorter median return of bowel function (3 vs 5 days, p < 0.0009) and length of stay (7 vs 10 days, p < 0.006). When comparing surgeons who performed greater than 40% cases laparoscopically to those with fewer than 40%, there was no difference in patient characteristics. There was no significant difference in return of bowel function, length of stay, post-operative mortality, or re-admission laparoscopic preferred or open preferred surgeons. CONCLUSION Laparoscopic intervention for the operative management of small bowel obstruction may provide superior clinical outcomes, shorter return of bowel function and length of stay compared to open operation, but patient selection for laparoscopic intervention is based on surgeon preference rather than patient characteristics.
Collapse
|
3
|
Lee MJ, Sayers AE, Drake TM, Singh P, Bradburn M, Wilson TR, Murugananthan A, Walsh CJ, Fearnhead NS. Malnutrition, nutritional interventions and clinical outcomes of patients with acute small bowel obstruction: results from a national, multicentre, prospective audit. BMJ Open 2019; 9:e029235. [PMID: 31352419 PMCID: PMC6661661 DOI: 10.1136/bmjopen-2019-029235] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess the nutritional status of patients presenting with small bowel obstruction (SBO), along with associated nutritional interventions and clinical outcomes. DESIGN Prospective cohort study. SETTING 131 UK hospitals with acute surgical services. PARTICIPANTS 2069 adult patients with a diagnosis of SBO were included in this study. The mean age was 67.0 years and 54.7% were female. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was in-hospital mortality. Secondary outcomes recorded included: major complications (composite of in-hospital mortality, reoperation, unplanned intensive care admission and 30-day readmission), complications arising from surgery (anastomotic leak, wound dehiscence), infection (pneumonia, surgical site infection, intra-abdominal infection, urinary tract infection, venous catheter infection), cardiac complications, venous thromboembolism and delirium. RESULTS Postoperative adhesions were the most common cause of SBO (49.1%). Early surgery (<24 hours postadmission) took place in 30.0% of patients, 22.0% underwent delayed operation and 47.9% were managed non-operatively. Malnutrition as stratified by Nutritional Risk Index was common, with 35.7% at moderate risk and 5.7% at severe risk of malnutrition. Dietitian review occurred in just 36.4% and 55.9% of the moderate and severe risk groups. In the low risk group, 30.3% received nutritional intervention compared with 40.7% in moderate risk group and 62.7% in severe risk group. In comparison to the low risk group, patients who were at severe or moderate risk of malnutrition had 4.2 and 2.4 times higher unadjusted risk of in-hospital mortality, respectively. Propensity-matched analysis found no difference in outcomes based on use or timing of parenteral nutrition. CONCLUSIONS Malnutrition on admission is associated with worse outcomes in patients with SBO, and marked variation in management of malnutrition was observed. Future trials should focus on identifying effective and cost-effective nutritional interventions in SBO.
Collapse
Affiliation(s)
- Matthew James Lee
- Department of General Surgery, Sheffield Teaching Hospitals NHS FT, Sheffield, South Yorkshire, UK
| | - Adele E Sayers
- General Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, Kingston upon Hull, UK
| | - Thomas M Drake
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Pritam Singh
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Timothy R Wilson
- General Surgery, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Ciaran J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK
| | - Nicola S Fearnhead
- Colorectal Surgery, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| |
Collapse
|
4
|
Thornblade LW, Verdial FC, Bartek MA, Flum DR, Davidson GH. The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review. J Gastrointest Surg 2019; 23:846-859. [PMID: 30788717 PMCID: PMC6988581 DOI: 10.1007/s11605-018-4017-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/18/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical training has long been to "never let the sun set on a bowel obstruction" without an operation to rule out and/or treat compromised bowel. However, advances in diagnostics have called into question the appropriate timing of non-emergent operations and expectant management is increasingly used. We performed a systematic review to evaluate the safety and effectiveness of expectant management for adhesive small bowel obstruction (aSBO) compared to early, non-emergent operation. MATERIALS & METHODS We queried PubMed, EMBASE, and Cochrane databases for studies (1990-present) comparing early, non-emergent operations and expectant management for aSBO (PROSPERO #CRD42017057676). RESULTS Of 4873 studies, 29 cohort studies were included for full-text review. Four studies directly compared early surgery with expectant management, but none excluded patients who underwent emergent operations from those having early non-emergent surgery, precluding a direct comparison of the two treatment types of interest. When aggregated, the rate of bowel resection was 29% in patients undergoing early operation vs. 10% in those undergoing expectant management. The rate of successful, non-operative management in the expectant group was 58%. There was a 1.3-day difference in LOS favoring expectant management (LOS 9.7 vs. 8.4 days), and the rate of death was 2% in both groups. CONCLUSION Despite the shift towards expectant management of aSBO, no published studies have yet compared early, non-emergent operation and expectant management. A major limitation in evaluating the outcomes of these approaches using existing studies is confounding by indication related to including patients with emergent indications for surgery on admission in the early operative group. A future study, randomizing patients to early non-emergent surgery or expectant management, should inform the comparative safety and value of these approaches.
Collapse
Affiliation(s)
- Lucas W Thornblade
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
| | - Francys C Verdial
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
| | - Matthew A Bartek
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA.
| | - David R Flum
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
| | - Giana H Davidson
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
| |
Collapse
|
5
|
Shi WH, Chao HQ, Ye NY, Shi HJ. Ileus tube placement combined with laparoscopy in the treatment of refractory small bowel obstruction: Case series and literature review. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii170020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Wei-Hai Shi
- Department of General Surgery, The Affiliated Wujin Hospital, Jiangsu University, Changzhou, China
| | - Hao-Qiang Chao
- Department of Radiology, The Affiliated Wujin Hospital, Jiangsu University, Changzhou, China
| | - Nian-Yuan Ye
- Department of General Surgery, The Affiliated Wujin Hospital, Jiangsu University, Changzhou, China
| | - Hong-Jian Shi
- Department of Radiology, The Affiliated Wujin Hospital, Jiangsu University, Changzhou, China
| |
Collapse
|
6
|
Jean RA, Chiu AS, O'Neill KM, Lin Z, Pei KY. The influence of sociodemographic factors on operative decision-making in small bowel obstruction. J Surg Res 2018; 227:137-144. [DOI: 10.1016/j.jss.2018.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/22/2018] [Accepted: 02/14/2018] [Indexed: 11/25/2022]
|
7
|
Brandt WS, Wood J, Bhattacharya B, Pei K, Davis KA, Schuster K. Relationship between duration of preoperative symptoms and postoperative ileus for small bowel obstruction. J Surg Res 2018; 225:40-44. [PMID: 29605033 DOI: 10.1016/j.jss.2017.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/20/2017] [Accepted: 12/19/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Factors associated with postoperative ileus and increased resource utilization for patients who undergo operative intervention for small-bowel obstruction are not extensively studied. We evaluated the association between total duration of preoperative symptoms and postoperative outcomes in this population. MATERIALS AND METHODS We performed a retrospective review of patients who underwent surgery for small-bowel obstruction (2013-2016). Clinical data were recorded. Total duration of preoperative symptoms included all symptoms before operation, including those before presentation. Primary endpoint was time to tolerance of diet. Secondary endpoints included length of stay, total parenteral nutrition use, and intensive care unit admission. Association between variables and outcomes was analyzed using univariable analysis, multivariable Poisson modeling, and t-test to compare groups. RESULTS Sixty-seven patients were included. On presentation, the median duration of symptoms before hospitalization was 2 d (range 0-18 d). Total duration of preoperative symptoms was associated with time to tolerance of diet on univariable analysis (Pearson's moment correlation: 0.28, 95% confidence interval: 0.028-0.5, P = 0.03). On multivariable analysis, ascites was correlated with time to tolerance of diet (P < 0.01), but total duration of preoperative symptoms (P = 0.07) was not. Length of stay (Pearson's correlation: 0.24, 95% confidence interval: -0.02 to 0.47, P = 0.07) was not statistically different in patients with longer preoperative symptoms. Symptom duration was not statistically associated with intensive care unit (P = 0.18) or total parenteral nutrition (P = 0.3) utilization. CONCLUSIONS Our findings demonstrate that preoperative ascites correlated with increased time to tolerance of diet, and duration of preoperative symptoms may be related to postoperative ileus.
Collapse
Affiliation(s)
- Whitney S Brandt
- Department of Surgery and New Haven, Sections of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut.
| | - Joshua Wood
- Department of Surgery and New Haven, Sections of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Bishwajit Bhattacharya
- Department of Surgery and New Haven, Sections of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Pei
- Department of Surgery and New Haven, Sections of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Kimberly A Davis
- Department of Surgery and New Haven, Sections of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Schuster
- Department of Surgery and New Haven, Sections of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
8
|
Outcomes After Surgery for Benign and Malignant Small Bowel Obstruction. J Gastrointest Surg 2017; 21:363-371. [PMID: 27783343 PMCID: PMC5263174 DOI: 10.1007/s11605-016-3307-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/11/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Small bowel obstruction (SBO) is a common diagnosis; however, outcomes of and risk factors for SBO and malignant bowel obstruction (MBO) surgery are not well understood. We sought to characterize outcomes and risk factors for surgery for SBO and MBO. METHODS A retrospective cohort study was performed utilizing prospectively collected data from the Michigan Surgical Quality Collaborative (7/2012-3/2015). Cases included those with ICD9 diagnosis code of bowel obstruction and CPT codes for lysis of adhesions, intestinal bypass, and small bowel resection. Cases were stratified by disseminated malignancy (MBO). Factors associated with complications and 30-day mortality were evaluated. RESULTS Two thousand two hundred thirty-three patients underwent surgery for bowel obstruction, including 86 patients (3.9 %) with MBO. MBO patients had an adjusted mortality rate of 14.5 % (benign 5.0 %); the adjusted complication rate was 32.2 % (benign 27.0 %). Factors independently associated with mortality included disseminated cancer, older age, American Society of Anesthesiologists IV/V, cirrhosis, ascites, urinary tract infection, sepsis, albumin <3.5, hematocrit <30, and bowel resection. CONCLUSIONS Surgery for bowel obstruction carries a relatively high risk for morbidity and mortality, particularly in patients with malignant bowel obstruction. Considering the identified risk factors for mortality may help clinicians make recommendations regarding surgery in the setting of MBO.
Collapse
|