The epidemiology and treatment patterns of postoperative adhesion induced intestinal obstruction in Varsinais-Suomi Hospital District

Intestinal obstruction in a tertiary care centre in India: Are the differences with the western experience becoming less?

Background

Patients with intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with a significant morbidity and mortality. It has a diverse aetiology which varies from country to country. In developed countries it is mainly due to adhesions and in developing countries due to obstructed hernias. Although there are numerous studies from the western world on this subject there have been few recent publications from the developing world.

Patients and methods

We retrospectively analyzed all the patients admitted with intestinal obstruction to our department from January 1996 to December 2019. Their demographic data, duration of symptoms before presenting to the hospital and interval between admission and surgery were noted along with the cause and level of obstruction. The type of procedure, post-operative complications, mortality or whether re-exploration was done were also noted. Post-operative complications were graded according to the Clavien Dindo classification.

Results

A total of 986 patients presented with intestinal obstruction during this period out of which 743 patients underwent surgery. The commonest cause of obstruction was adhesions in 273 (36.7%) – the proportion increased significantly from 23% in 1996–2004 to 51.6% in 2013–2019. This was followed by carcinoma [130(17.5%)], tuberculosis [111(14.9%)], strictures [94(12.7%)] and hernia (5.4%). Colorectal surgery was the most common previous procedure in the adhesions group [85(31.1%)].The overall operative mortality was 41 (5.5%).

Conclusion

The aetiology of intestinal obstruction in our hospital is now mainly due to adhesions and is thus shifting towards the western pattern. But tuberculosis and obstructed inguinal hernias still constitute of a sizable proportion of our patients.

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Post-operative adhesions have now become a common cause of intestinal obstruction our tertiary care centre situated in a developing country.

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These were most commonly preceded by operations on the colon and rectum.

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Our overall mortality rate was comparable with those reported from the west. Old age, malignancy and strangulation were associated with a higher risk of mortality as has been the experience from other centres.

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Compared to Western reports our patient population was younger, males predominated.

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Although the proportion of patients with adhesions is rising tuberculosis continues to be an important cause for intestinal obstruction.

Characteristics of Intestinal Volvulus and Risk of Mortality in Malawi

BACKGROUND

Intestinal volvulus is a common cause of mechanical intestinal obstruction (MIO) in Africa. Sigmoid volvulus has been well characterized in both high-income and low-income countries, but there is also a predilection for small bowel volvulus in sub-Saharan Africa.

METHODS

An analysis was performed of the Kamuzu Central Hospital Acute Care Surgery Registry from 2013 to 2019 on patients presenting with intestinal volvulus. Bivariate analysis was performed for covariates based on the intestinal volvulus type. Multivariate Poisson regression models estimated the relative risk of volvulus and mortality.

RESULTS

A total of 4352 patients were captured in the registry. Overall, 1037 patients (23.8%) were diagnosed with MIO. Intestinal volvulus accounted for 499 (48.1%) of patients with MIO. Sigmoid volvulus, midgut volvulus, ileosigmoid knotting, and cecal volvulus accounted for 57.7% (n = 288), 19.8% (n = 99), 20.8% (n = 104), and 1.6% (n = 8), respectively. Mean age was 46.8 years (SD 17.2) with a male preponderance (n = 429, 86.0%) and 14.8% (n = 74) mortality. Overall, the most common operations performed were large bowel (n = 326, 74.4%) and small bowel (n = 76, 16.7%) resections with 18.0% (n = 90) ostomy formation. Upon regression modeling, the relative risk for volvulus was 2.7 times higher in men than women after controlling for season and age. There was no statistically significant difference in the relative risk of mortality based on the type of volvulus.

CONCLUSION

Volvulus is a significant cause of primary bowel obstruction in sub-Saharan Africa. Type of intestinal volvulus is not associated increased risk of mortality. Reasons for increases in the incidence of small bowel volvulus are still largely undetermined.

Etiologic Spectrum of Intestinal Obstruction in Ningxia District: A Retrospective Analysis of 4908 Cases in a 10-Year Period

Background

Economic disparity contributes to the variation of intestinal obstruction (IO) etiologic spectrum. Clarifying the etiology distribution in local regions can help to unravel IO and promote early diagnosis, henceforth making sure standardized therapeutic interventions.

Methods

Medical data of 4908 inpatients diagnosed with IO admitted to the General Hospital of Ningxia Medical University between January 2004 and December 2013 were recruited and analyzed retrospectively. The associated profiles included demographic features, clinical manifestations, and previous therapeutic operations.

Results

4908 cases of intestinal obstruction were identified during the period of study. It denoted that the hospitalization rate of IO has maintained upward momentum; the top four causes of IO were adhesion, tumor, intussusception, and hernias. These covered up nearly 80% of the total constitution. Among them, adhesive intestinal obstruction accounted for 45.17%, malignant bowel obstruction for 21.09%, intussusception for 8.72%, and hernia for 4.73%; abdominal surgery constituted for the majority (78.62%) of adhesive obstruction. The followed up analysis also found that appendectomy accounted for the biggest percentage, 28% of operation cases. Malignant bowel obstruction can have a rate of 96.43% in 1035 cases led by tumor lesions. Of which, the primary intestinal malignant tumor accounted for 68.64% and metastatic tumors for 31.36%. Nearly 50% occurred in the large intestine. The overall mortality of all 4908 cases was 4.7%.

Conclusion

The hospitalizations of IO delineated an increasing trend. Adhesion was the main etiology in IO. The odds of malignant bowel obstruction was increasing in the proportion of IO. There were some differences towards the etiologic spectrum compared with western countries.

The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review

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.

Progressive Fibrosis: A Progesterone- and KLF11-Mediated Sexually Dimorphic Female Response

Progressive scarring is ubiquitous postoperatively and in an array of chronic systemic diseases. Recent studies indicate that such scarring has a high female propensity; females are also almost exclusively affected by endometriosis, a common sex steroid-dependent fibrotic disease. Endometriosis-related fibrosis is regulated epigenetically through transcription factor Krüppel-like factor 11 (KLF11). In response to surgical induction of endometriosis, Klf11-/- female mice develop significant fibrosis in contrast to wild-type mice. We therefore hypothesized that female fibrotic predilection was mediated by differential sex steroid regulation of KLF11/collagen 1a1 signaling and investigated the fibrotic response in wild-type and Klf11-/- male and female animals using a sterile peritonitis model. Fibrosis selectively developed in Klf11-/- females. Fibrosis in these animals was almost completely abrogated by ovariectomy. Ovariectomized animals were selectively supplemented with estradiol, medroxyprogesterone acetate (MPA), or dihydrotestosterone; fibrosis was only observed in mice exposed to MPA. Fibrosis therefore selectively developed in Klf11-/- female mice in response to physiological or pharmacological progesterone. The fibrotic response in these animals was also mitigated in response to antiprogestin therapy. Profibrotic gene expression was activated in a primary human peritoneal cell line in response to KLF11 short hairpin RNA and MPA but not estradiol. KLF11/collagen 1a1 signaling previously shown to be linked to fibrosis was thus selectively dysregulated in MPA-treated cells. Our in vivo and in vitro findings in an animal model and human cells, respectively, suggest that progressive fibrotic scarring is a sexually dimorphic response irrespective of etiology; moreover, it is responsive to novel, individualized therapeutic intervention.

Surgical indicators for the operative treatment of acute mechanical intestinal obstruction due to adhesions

Purpose

Our aim was to investigate the predictive factors indicating strangulation, and the requirement for surgery in patients with acute mechanical intestinal obstruction due to adhesions.

Methods

This study retrospectively evaluated the records of patients with adhesive acute mechanical intestinal obstruction. The surgical treatment (group S), conservative treatment (group C), intraoperative bowel ischemia (group I), and intraoperative adhesion only (group A) groups were statistically evaluated according to the diagnostic and surgical parameters.

Results

The study group of 252 patients consisted of 113 women (44.8%), and 139 men (55.2%). The mean age was 62.79 ± 18.08 years (range, 20-98 years). Group S consisted of 50 patients (19.8%), and 202 (80.2%) were in group C. Group I consisted of 19 patients (38%), where as 31 (62%) were in group A. In group S, the prehospital symptomatic period was longer, incidence of fever was increased, and elevated CRP levels were significant (P < 0.05). Plain abdominal radiography, and abdominal computerized tomography were significantly sensitive for strangulation (P < 0.05). The elderly were more prone to strangulation (P < 0.05). Fever, rebound tendernes, and urea & creatinine levels were significantly higher in the presence of strangulation (P < 0.05, P < 0.05, and P < 0.05, consecutively).

Conclusion

Fever, rebound tenderness, urea & creatinine levels, plain abdominal radiography, and abdominal computerized tomography images were important indicators of bowel ischemia. Longer prehospital symptomatic period was related with a tendency for surgical treatment, and the elderly were more prone to strangulation. CRP detection was considered to be useful for the decision of surgery, but not significantly predictive for strangulation.

Ileus and intestinal obstruction--comparison between children and adults

Bowel obstruction is the interference with movement of bowel content. Large and small in testing from duodenum to anal region can be obstructed mechanical or non-mechanical and complete or partial. Mechanical obstruction can presented because of obstructive causes in intestinal lumen, intestinal wall or pressure from other tissue on intestine. The aim of the study was to evaluate etiology, laboratory findings of intestinal obstruction and ileus among children and adults who discharged with good condition.

MATERIAL AND METHODS

This retrospective study was carried out from 2001 to 2006 in Imam Khomeini Hospital (Ahvaz-Iran). Cases of bowel obstruction were included in this study. For each case, a questionnaire was filled. There are 752 cases with suspected bowel obstruction. From 752 cases, 403 patients that agreed and treated and discharged with good condition were studied. Cases were divided into two groups: children (age < 15 yrs) and adults (age> 15 yrs). Data were analyzed by SPSS Ver 16.0 (Chicago, IL, USA) and Epi-info Ver 6.00.

RESULTS

In our study, 221 adults and 192 children were included. Mortality rate was 12.2%. Forty-eight percent of 403 cases were children (m - 61%, f - 38%, ambigus genitalia - 1%) and 52% were adults (m - 67%, f - 33%). Etiology of bowel obstruction in children were as follows: ileus (26%); adhesion band (17.7%), partial obstruction (16.1%), and Hirschsprung's disease (12%). Causes of bowel obstruction in adults are: partial obstruction (29.9%); ileus (19%); adhesion band (18.5%); colonic pseudo obstruction(8.5%); GI cancer (5.2%); hernia (4.7%); Crohn (2.8%); fecal impaction (3.3%); bezoar (2.4%), and 4.7% for other causes. Fifty-one percent of children and 36% of adults were operated. Of all children, 91.7% had upright abdominal X-ray, 51.6% had supine X-ray, and 80.7% had sonography. Hundred percents of adults had upright & supine plain abdominal X-ray and 75.4% had sonography. Most change in children's CBC was 10000<WBC<15000 and in adult for WBC<10000.

CONCLUSIONS

Partial obstruction, pseudo-obstruction, and cancer were more common in adults than children. Ileus was the commonest cause of obstruction in children and it was partial obstruction for adult. Children were more operated than adult. Sonography was more use for children but plain abdominal X-ray for adult. In 45% of children 10000<WBC<15000 while most adult had WBC<10000. Hypokalemia was the most common biochemical finding in both group.

[Postoperative abdominal adhesions and their prevention in gynaecological surgery: I. What should you know?]

Adhesions are the most frequent complications of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with increased morbidity and mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, including laparoscopy, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in many patients. The extent of the problem of adhesions has been underestimated by surgeons and the health authorities. There is rising evidence however that surgeons can take important steps to reduce the impact of adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. This paper is the first of a two-part publication providing a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. In the second paper we review the various strategies to reduce the impact of adhesions and improve surgical outcomes to assist fellow surgeons in France to consider the adoption of adhesion reduction strategies in their own practice.

Pattern of acute intestinal obstruction: is there a change in the underlying etiology?

BACKGROUND/AIM

To study the changing pattern of acute intestinal obstruction at a teaching institute.

PATIENTS AND METHODS

It is a prospective descriptive study conducted at a teaching hospital during the period from June 2004 to June 2009. All patients with clinical or radiological evidence of acute intestinal obstruction were included in this study regardless of the gender of the patient. Patients below the age of 10 years were excluded from the study. The treatment strategy was planned ranging from conservative treatment to emergency laparotomy after resuscitation and rehydration of the patient. Details of individual patients were recorded on a pro forma sheet and data analyzed statistically on SPSS version 14.

RESULTS

A total of 229 patients with acute intestinal obstruction were admitted and treated. The mean age of the study population was 43.08 ± 13.07 years. Postoperative adhesions accounted for 41% (n = 95) of the total cases, followed by abdominal tuberculosis (25%, n = 58), obstructed/ strangulated hernias of different types (18%, n = 42). There was an obvious change in the pattern of etiology of acute intestinal obstruction as the common causes were postoperative adhesions and abdominal tuberculosis instead of obstructed inguinal hernias.

CONCLUSION

An increase in the adhesive obstruction and a concomitant decrease in the incidence of obstructed hernias indicate a changing trend towards early operation before it gets complicated. Abdominal tuberculosis is emerging as another common cause of acute bowel obstruction.

Understanding weight loss in patients with colorectal cancer: a human response to illness

PURPOSE/OBJECTIVES

To provide a comprehensive overview of weight loss in patients with colorectal cancer (CRC) within the context of the Human Response to Illness (HRTI) model.

DATA SOURCES

Research from 1990-2008 and classic research from the 1980s were included. PubMed, CINAHL(R), and Google Scholar were searched for the terms cancer, CRC, weight loss, and cancer cachexia.

DATA SYNTHESIS

Progressive, unintentional weight loss is a common issue in patients with CRC that has a devastating effect on patients' self-image, quality of life, and survival. Physiologic abnormalities, responses to the tumor, and treatments contribute to weight loss in these patients. In addition, cancer cachexia is an end-stage wasting syndrome and a major cause of morbidity and mortality in this population.

CONCLUSIONS

The HRTI model provides an appropriate framework to gain a comprehensive understanding of the physiologic, pathophysiologic, behavioral, and experiential perspectives of weight loss and cancer cachexia in patients with CRC.

IMPLICATIONS FOR NURSING

By examining weight loss in patients with CRC within the context of the four perspectives of the HRTI model, oncology and gastroenterology nurses can gain insight into optimal, evidence-based assessment and management of this patient population. In addition, current gaps in knowledge can be identified and provide guidance for future nursing research.

Acute mechanical bowel obstruction: Clinical presentation, etiology, management and outcome

AIM: To identify and analyze the clinical presentation, management and outcome of patients with acute mechanical bowel obstruction along with the etiology of obstruction and the incidence and causes of bowel ischemia, necrosis, and perforation.

METHODS: This is a prospective observational study of all adult patients admitted with acute mechanical bowel obstruction between 2001 and 2002.

RESULTS: Of the 150 consecutive patients included in the study, 114 (76%) presented with small bowel and 36 (24%) with large bowel obstruction. Absence of passage of flatus (90%) and/or feces (80.6%) and abdominal distension (65.3%) were the most common symptoms and physical finding, respectively. Adhesions (64.8%), incarcerated hernias (14.8%), and large bowel cancer (13.4%) were the most frequent causes of obstruction. Eighty-eight patients (58.7%) were treated conservatively and 62 (41.3%) were operated (29 on the first day). Bowel ischemia was found in 21 cases (14%), necrosis in 14 (9.3%), and perforation in 8 (5.3%). Hernias, large bowel cancer, and adhesions were the most frequent causes of bowel ischemia (57.2%, 19.1%, 14.3%), necrosis (42.8%, 21.4%, 21.4%), and perforation (50%, 25%, 25%). A significantly higher risk of strangulation was noticed in incarcerated hernias than all the other obstruction causes.

CONCLUSION: Absence of passage of flatus and/or feces and abdominal distension are the most common symptoms and physical finding of patients with acute mechanical bowel obstruction, respectively. Adhesions, hernias, and large bowel cancer are the most common causes of obstruction, as well as of bowel ischemia, necrosis, and perforation. Although an important proportion of these patients can be nonoperatively treated, a substantial portion requires immediate operation. Great caution should be taken for the treatment of these patients since the incidence of bowel ischemia, necrosis, and perforation is significantly high.