Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

Neutrophil to lymphocyte ratio predicts bowel ischemia in non-strangulated adhesive small bowel occlusions: a retrospective analysis from an acute care surgical service

BACKGROUND

Adhesive small bowel obstruction (ASBO) is a leading cause of hospitalization in emergency surgery. The occurrence of bowel ischemia significantly increases the morbidity and mortality rates associated with this condition. Current clinical, biochemical and radiological parameters have poor predictive value for bowel ischemia. This study is designed to ascertain predictive elements for the progression to bowel ischemia in patients diagnosed with non-strangulated ASBO who are initially managed through conservative therapeutic approaches.

METHODS

The study was based on the previously collected medical records of 128 patients admitted to the Department of Acute Care Surgery of Padua General Hospital, from August 2020 to April 2023, with a diagnosis of non-strangulated adhesive small bowel obstruction, who were then operated for failure of conservative treatment. The presence or absence of bowel ischemia was used to distinguish the two populations. Clinical, biochemical and radiological data were used to verify whether there is a correlation with the detection of bowel ischemia.

RESULTS

We found that a Neutrophil-Lymphocyte ratio (NLR) > 6.8 (OR 2.9; 95% CI 1.41-6.21), the presence of mesenteric haziness (OR 2.56; 95% CI 1.11-5.88), decreased wall enhancement (OR 4.3; 95% CI 3.34-10.9) and free abdominal fluid (OR 2.64; 95% CI 1.08-6.16) were significantly associated with bowel ischemia at univariate analysis. At the multivariate logistic regression analysis, only NLR > 6.8 (OR 5.9; 95% CI 2.2-18.6) remained independent predictive factor for small bowel ischemia in non-strangulated adhesive small bowel obstruction, with 78% sensitivity and 65% specificity.

CONCLUSIONS

NLR is a straightforward and reproducible parameter to predict bowel ischemia in cases of non-strangulated adhesive small bowel obstruction. Employing NLR during reevaluation of patients with this condition, who were initially treated conservatively, can help the acute care surgeons in the early prediction of bowel ischemia onset.

Prevention of post-operative adhesions: Model development and pilot outcomes of human placental stem cell-based interventions

BACKGROUND

Abdominal adhesions are the most common surgical complication and without reliable prophylactics. This study presents a novel rat model for abdominal adhesions and reports pilot results of human placental stem cell (hPSC)-based therapies.

METHODS

Forty-four (n = 44) male Sprague-Dawley rats (250-350 g) were used in the experiment. Of these, thirty-eight (n = 38) were included in a preliminary data set to determine a minimum treatment effect. Adhesions were created in a reproducible model to the abdominal wall and between organs. Experimental groups included the control group (Model No Treatment, MNT), Plasmalyte A (Media Alone, MA, 10 mL), hPSC (5 × 106 cells/10 mL Plasmalyte A), hPSC-CM (hPSC secretome, conditioned media) in 10 mL Plasmalyte A, Seprafilm™ (Baxter, Deerfield, IL), and sham animals (laparotomy only). Treatments were inserted intraperitoneally (IP) and the study period was 14 days post-operation. Results are reported as the difference between means of an index statistic (AIS, Animal Index Score) and compared by ANOVA with pairwise comparison.

RESULTS

The overall mean AIS was 23 (SD 6.16) for the MNT group with an average of 75% of ischemic buttons involved in abdominal adhesions. Treatment groups MA (mean overall AIS 17.33 SD 6.4), hPSC (mean overall AIS 13.86 SD 5.01), hPSC-CM (mean overall AIS 13.13 SD 6.15), and Seprafilm (mean overall AIS 13.43 SD 9.11) generated effect sizes of 5.67, 9.14, 9.87, and 9.57 decrease in mean overall AIS, respectively, versus the MNT.

DISCUSSION

The presented rat model and scoring system represent the clinical adhesion disease process. hPSC-based interventions significantly reduce abdominal adhesions in this pilot dataset.

Research landscape of abdominal adhesions from 2004 to 2023: A bibliometric analysis

Adhesions are the most common complication of abdominal or pelvic surgery and remain a challenging problem. To better understand the development tendency of abdominal adhesions, we performed a comprehensive bibliometric analysis of the field of abdominal adhesions. In total, 2219 articles regarding abdominal adhesions were screened and analyzed from 3410 manuscripts indexed in the Web of Science-indexed manuscripts regarding abdominal adhesion from 2004 to 2023. A bibliometric analysis was performed, and CiteSpace [version 6.2. R3 (64-bit)] and VOSviewer (version 1.6.19) were used to visualize the results. The number of annual publications showed slight growth before 2019, and the USA contributed the most publications. The most prolific author in this domain was Diamond, while the publications from Ten Broek had the strongest influence. The most popular journal in this field was the Journal of Surgical Research, and the most frequently co-cited journal was Fertility and Sterility. After analyzing the keywords, "prevention", "surgery" and "peritoneal adhesion" were the 3 most co-cited keywords, while "adhesive small bowel obstruction" was the strongest keyword in the citation burst. Here, for the first time, we used bibliometric methods to study abdominal adhesions over the past ten years. By summarizing the characteristics of publications and predicting future research prospects, we established a framework for researchers and provided a basis for subsequent research.

Effect of modified gastrointestinal decompression under abdominal CT in patients with intestinal obstruction

INTRODUCTION

We aimed to evaluate the effect of continuous quality improvement on modified gastrointestinal decompression under abdominal computed tomography (CT) in patients with intestinal obstruction.

METHODS

The CT images of 74 patients with intestinal obstruction who underwent gastrointestinal decompression in our hospital from 1 January 2018 to 31 December 2019 were analysed retrospectively (Control group). Factors influencing unsatisfactory decompression effects were analysed, and corresponding improvement measures were formulated and implemented. A total of 77 patients from 1 January 2020 to 31 March 2022 were enrolled prospectively (Study group). The position of the nasogastric tube end, the amount of gastric drainage within 24h and the degree of abdominal distension relief were compared before and after the improvement.

RESULTS

After implementation of continuous quality improvement, the proportion of the end of the nasogastric tube reaching the antrum, the amount of gastric fluid drainage within 24h and the degree of abdominal distension relief were better than those before improvement (p<0.001, respectively). The execution rate and accuracy rate of CT interpretations by nurses reached 100% and 82%, respectively.

CONCLUSIONS

Modified gastrointestinal decompression based on abdominal CT scans can increase the success of gastrointestinal decompression and effectively reduce the discomfort of patients.

Comparison of the effect between traditional conservation and nasointestinal tube placement in adhesive small bowel obstruction: A matched case-control study

Adhesive small bowel obstruction (ASBO) causes a major burden in emergency medicine. Owing to in situ decompression, nasointestinal tube (NIT) placement has been increasingly used in clinical practice compared with traditional conservation (TC); however, the indications remain controversial. This study was designed to explore the indications for each treatment in ASBOs and then suggest the optimal strategy. After propensity score matching, 128 pairs were included (the NIT and TC groups). The occurrence of severe adverse events (SAEs), peri-treatment clinical parameters, and radiological features were compared between the successful and failed treatment groups. According to different stages of the entire treatment, the independent risk factors for adverse effects for ASBO were analysed in phase I and phase II. In phase I, normal red blood cells (RBC) levels (p = 0.011) and a balanced sodium ion level (p = 0.016) positively affected the outcomes of TC treatment. In phase II, for the TC group, the successful treatment rate reached 79.5% for patients with ASBOs whose normal RBC levels (p = 0.006) or decreasing white blood cells (WBC) levels (p = 0.014) after treatment. For the NIT group, the treatment success rate was 68.1% for patients whose electrolyte imbalance could be reversed or whose neutrophil count/lymphocyte ratio (NLR) levels was lower than 4.3 (p = 0.018). TC treatment is highly recommended for patients with normal RBC counts and sodium levels pretreatment. After dynamic monitoring of the treatment process, for both the TC and NIT groups, once ASBOs had elevated inflammatory biomarkers or irreversible electrolyte disturbances, surgical interference was preferred.

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.

A novel nomogram integrating body composition and inflammatory-nutritional markers for predicting postoperative complications in patients with adhesive small bowel obstruction

Background

Postoperative complications in adhesive small bowel obstruction (ASBO) significantly escalate healthcare costs and prolong hospital stays. This study endeavors to construct a nomogram that synergizes computed tomography (CT) body composition data with inflammatory-nutritional markers to forecast postoperative complications in ASBO.

Methods

The study's internal cohort consisted of 190 ASBO patients recruited from October 2017 to November 2021, subsequently partitioned into training (n = 133) and internal validation (n = 57) groups at a 7:3 ratio. An additional external cohort comprised 52 patients. Body composition assessments were conducted at the third lumbar vertebral level utilizing CT images. Baseline characteristics alongside systemic inflammatory responses were meticulously documented. Through univariable and multivariable regression analyses, risk factors pertinent to postoperative complications were identified, culminating in the creation of a predictive nomogram. The nomogram's precision was appraised using the concordance index (C-index) and the area under the receiver operating characteristic (ROC) curve.

Results

Postoperative complications were observed in 65 (48.87%), 26 (45.61%), and 22 (42.31%) patients across the three cohorts, respectively. Multivariate analysis revealed that nutrition risk score (NRS), intestinal strangulation, skeletal muscle index (SMI), subcutaneous fat index (SFI), neutrophil-lymphocyte ratio (NLR), and lymphocyte-monocyte ratio (LMR) were independently predictive of postoperative complications. These preoperative indicators were integral to the nomogram's formulation. The model, amalgamating body composition and inflammatory-nutritional indices, demonstrated superior performance: the internal training set exhibited a 0.878 AUC (95% CI, 0.802-0.954), 0.755 accuracy, and 0.625 sensitivity; the internal validation set displayed a 0.831 AUC (95% CI, 0.675-0.986), 0.818 accuracy, and 0.812 sensitivity. In the external cohort, the model yielded an AUC of 0.886 (95% CI, 0.799-0.974), 0.808 accuracy, and 0.909 sensitivity. Calibration curves affirmed a strong concordance between predicted outcomes and actual events. Decision curve analysis substantiated that the model could confer benefits on patients with ASBO.

Conclusion

A rigorously developed and validated nomogram that incorporates body composition and inflammatory-nutritional indices proves to be a valuable tool for anticipating postoperative complications in ASBO patients, thus facilitating enhanced clinical decision-making.

The significance of initial lactate levels in emergency department presentations of abdominal wall hernia

INTRODUCTION

Abdominal wall hernias are a frequent cause of abdominal pain-related emergency department visits. Our study aimed to establish the connection between lactate levels and patient outcomes in those with abdominal pain due to abdominal wall hernias.

MATERIALS AND METHODS

Our research followed a retrospective, observational, and descriptive approach and two center. We included patients who visited the emergency department for abdominal pain and were confirmed to have abdominal wall hernias through ultrasound.

RESULTS

We enrolled 493 patients meeting the criteria. Median age was 65 years, with 54% (n = 266) being male. Regarding outcomes, 40.5% (n = 200) were hospitalized, 27.7% (n = 137) underwent surgery, and 7.9% (n = 39) underwent bowel resection. Mortality rate during hernia-related hospital admission was 0.6% (n = 3). For hospitalized patients, there were significant differences in white blood cell count, neutrophil count and percentage, platelet count, lymphocyte count, and percentage (p < 0.05). Patients undergoing resection showed significant differences in neutrophil count, neutrophil percentage, lymphocyte count, and lymphocyte percentage (p < 0.05). Lactate levels were statistically significant in all patient groups requiring hospitalization, surgery, and resection (p < 0.05). Sensitivity and specificity of lactate test results indicated in patients undergoing bowel resection, lactate values ≥1.96 mmol/L had a specificity of 64%, sensitivity of 71%, and a negative predictive value of 96% (p < 0.05).

CONCLUSION

Low lactate levels in patients presenting to the emergency department with abdominal pain caused by abdominal wall hernias have a high negative predictive value for excluding strangulation and the need for bowel resection. Therefore, we recommend the use of lactate as an additional diagnostic tool in emergency department presentations related to abdominal wall hernias.

Prediction of bowel necrosis by reduced bowel wall enhancement in closed-loop small bowel obstruction: Quantitative methods

PURPOSE

To assess diagnostic performance and reproducibility of reduced bowel wall enhancement evaluated by quantitative methods using CT to identify bowel necrosis among closed-loop small bowel obstruction (CL-SBO) patients.

METHODS

This retrospective single-center study included patients who diagnosed with CL-SBO caused by adhesion or internal hernia during January 2016 and May 2022. Patients were divided into necrotic group (n = 41) and non-necrotic group (n = 67) according to surgical exploration and postoperative pathology. Two doctors independently measured the attenuation of bowel wall and consensus was reached through panel discussion with a third gastrointestinal radiologist. Reduced bowel wall enhancement was assessed by four quantitative methods. Univariate analyses were used to evaluate the association between each method and bowel necrosis, and kappa/intraclass correlation coefficient values were used to assess interobserver agreement. Diagnostic performance parameters were calculated for each method.

RESULTS

Reduced bowel wall enhancement in arterial phase (OR 8.98, P < 0.0001), reduced bowel wall enhancement in portal phase (OR 16.84, P < 0.001), adjusted reduced bowel wall enhancement in arterial phase (OR 29.48, P < 0.001), adjusted reduced bowel wall enhancement in portal phase (OR 145.69, P < 0.001) were significantly associated with bowel necrosis. Adjusted reduced bowel wall enhancement in portal phase had the best diagnostic performance (AUC: 0.92; Youden index: 0.84; specificity: 94.03 %) and interobserver agreement (kappa value of 0.59-0.73) to predict bowel necrosis.

CONCLUSION

When assessing reduced bowel enhancement to predict bowel necrosis among CL-SBO patients, using unenhanced CT images and proximal dilated loop as standard references in portal phase is the most accurate quantitative method among those tested.

Tissue-mimicking composite barrier membranes to prevent abdominal adhesion formation after surgery

Postoperative abdominal adhesions often occur after abdominal surgery; barrier membranes which mimic peritoneal tissue can be constructed to prevent abdominal adhesions. To this end, silk fibroin (SF) sheets were coated with polyvinyl alcohol (PVA) and agarose (AGA) at PVA:AGA ratios of 100:0, 70:30, 50:50, 30:70, and 0:100 to create a composite anti-adhesive barrier and allow us to identify a suitable coating ratio. The membranes were characterized in terms of their molecular organization, structure, and morphology using Fourier transform Infrared spectrometer (FT-IR), differential scanning calorimeter (DSC), and scanning electron microscope (SEM), respectively. The physical and mechanical properties of the membranes and their biological performance (i.e., fibroblast proliferation and invasion) were tested in vitro. Each membrane showed both smooth and rough surface characteristics. Membranes coated with PVA:AGA at ratios of 100:0, 70:30, 50:50, and 30:70 exhibited more -OH and amide III moieties than those coated with 0:100 PVA:AGA, which consequently affected structural organization, degradation, and fibroblast viability. The 0:100 PVA:AGA-coated degraded the fastest. Barrier membranes coated with 100:0 and 70:30 PVA: AGA demonstrated reduced fibroblast proliferation and attachment. The membrane coated with 70:30 PVA:AGA exhibited a stable appearance, and did not curl under wet conditions. Therefore, SF sheets coated with 70:30 PVA:AGA show promise as anti-adhesive barrier membranes for further development.

Adhesive small bowel obstruction: predictive factors of laparoscopic failure

The adoption of laparoscopy for the management of adhesive small bowel obstruction (ASBO) patients is debated. The laparoscopic approach has been associated with a considerable conversion-to-open rate. Nonetheless, reliable predictors of conversion are still unclear. The present study aimed to identify factors associated with conversion to open in ASBO patients who underwent laparoscopic surgery. Patients who underwent laparoscopic surgery for ASBO and were admitted to our unit between December 2014 and October 2022 were retrospectively evaluated. The patients were categorized into two groups: patients who underwent complete laparoscopy approach (Group 1) and patients converted to open technique (Group 2). Demographic, clinical, and radiological features, intraoperative findings, and postoperative outcomes were compared. A total of 168 patients were enrolled: 100 patients (59.5%) were included in Group 1, and 68 patients (40.5%) were included in Group 2. The rate of ischemia (p = 0.023), surgical complications (p = 0.001), operative time (p < 0.0001), days of nasogastric tube maintenance (p < 0.0001), time to canalization (p < 0.0001), and length of hospital stay (p < 0.0001) were significantly higher in Group 2 than Group 1. Following univariate analysis, the presence of feces signs (p = 0.044) and high mean radiodensity of intraperitoneal free fluid (p = 0.031) were significantly associated with Group 2 compared with Group 1. Following multivariate analysis, the feces sign was a significant predictive factor of conversion (OR 1.965 [IC 95%]; p = 0.046). Laparoscopic treatment is a safe and effective approach in patients affected by ASBO. The feces sign may be a predictive factor of conversion and could guide the surgeon in selecting the appropriate management of patients affected by ASBO.

European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities

BACKGROUND

European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature.

METHODS

Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society.

RESULTS

Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training.

CONCLUSIONS

This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.

Assessing risk of recurrent small bowel obstruction after non-operative management in patients with history of intra-abdominal surgery: a population-based comprehensive analysis in Taiwan

BACKGROUND

Despite a significant 30% ten-year readmission rate for SBO patients, investigations into recurrent risk factors after non-operative management are scarce. The study aims to generate a risk factor scoring system, the 'Small Bowel Obstruction Recurrence Score' (SBORS), predicting 6-month recurrence of small bowel obstruction (SBO) after successful non-surgical management in patients who have history of intra-abdominal surgery.

METHODS

We analyzed data from patients aged ≥ 18 with a history of intra-abdominal surgery and diagnosed with SBO (ICD-9 code: 560, 568) and were successful treated non-surgically between 2004 and 2008. Participants were divided into model-derivation (80%) and validation (20%) group.

RESULTS

We analyzed 23,901 patients and developed the SBORS based on factors including the length of hospital stay > 4 days, previous operations > once, hemiplegia, extra-abdominal and intra-abdominal malignancy, esophagogastric surgery and intestino-colonic surgery. Scores > 2 indicated higher rates and risks of recurrence within 6 months (12.96% vs. 7.27%, OR 1.898, p < 0.001 in model-derivation group, 12.60% vs. 7.05%, OR 1.901, p < 0.001 in validation group) with a significantly increased risk of mortality and operative events for recurrent episodes. The SBORS model demonstrated good calibration and acceptable discrimination, with an area under curve values of 0.607 and 0.599 for the score generation and validation group, respectively.

CONCLUSIONS

We established the effective 'SBORS' to predict 6-month SBO recurrence risk in patients who have history of intra-abdominal surgery and have been successfully managed non-surgically for the initial obstruction event. Those with scores > 2 face higher recurrence rates and operative risks after successful non-surgical management.

Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer

INTRODUCTION

This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC).

METHODS

Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups.

RESULTS

The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n =68/1544 vs. 9.7%, n =156/1604, P <0.0001). Compared with the TOS group, the MIS group had significantly different ( P <0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to ( P <0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3-12 months) onset (64.7%), while that in the TOS group ( P <0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more ( P <0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8 vs. 14.1%, P =0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group.

CONCLUSIONS

The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.

Pearls and Pitfalls of Imaging Small Bowel Obstruction

Small bowel obstruction (SBO) is a common condition encountered by radiologists in the evaluation of patients with abdominal pain, and is an important diagnosis to be comfortable with given substantial associated morbidity and mortality. In this review, we summarize an imaging approach to evaluating patients with suspected SBO, discuss the role of certain imaging modalities such as radiography and small bowel follow through, CT, and MRI, as well as review some common and also less common causes of SBO such as internal hernia. We will also discuss tailoring the imaging approach to address specific clinical questions and special patient populations such as imaging the pregnant patient with suspected SBO, and the inflammatory bowel disease patient.

Deep learning for automatic bowel-obstruction identification on abdominal CT

RATIONALE AND OBJECTIVES

Automated evaluation of abdominal computed tomography (CT) scans should help radiologists manage their massive workloads, thereby leading to earlier diagnoses and better patient outcomes. Our objective was to develop a machine-learning model capable of reliably identifying suspected bowel obstruction (BO) on abdominal CT.

MATERIALS AND METHODS

The internal dataset comprised 1345 abdominal CTs obtained in 2015-2022 from 1273 patients with suspected BO; among them, 670 were annotated as BO yes/no by an experienced abdominal radiologist. The external dataset consisted of 88 radiologist-annotated CTs. We developed a full preprocessing pipeline for abdominal CT comprising a model to locate the abdominal-pelvic region and another model to crop the 3D scan around the body. We built, trained, and tested several neural-network architectures for the binary classification (BO, yes/no) of each CT. F1 and balanced accuracy scores were computed to assess model performance.

RESULTS

The mixed convolutional network pretrained on a Kinetics 400 dataset achieved the best results: with the internal dataset, the F1 score was 0.92, balanced accuracy 0.86, and sensitivity 0.93; with the external dataset, the corresponding values were 0.89, 0.89, and 0.89. When calibrated on sensitivity, this model produced 1.00 sensitivity, 0.84 specificity, and an F1 score of 0.88 with the internal dataset; corresponding values were 0.98, 0.76, and 0.87 with the external dataset.

CONCLUSION

The 3D mixed convolutional neural network developed here shows great potential for the automated binary classification (BO yes/no) of abdominal CT scans from patients with suspected BO.

CLINICAL RELEVANCE STATEMENT

The 3D mixed CNN automates bowel obstruction classification, potentially automating patient selection and CT prioritization, leading to an enhanced radiologist workflow.

KEY POINTS

• Bowel obstruction's rising incidence strains radiologists. AI can aid urgent CT readings. • Employed 1345 CT scans, neural networks for bowel obstruction detection, achieving high accuracy and sensitivity on external testing. • 3D mixed CNN automates CT reading prioritization effectively and speeds up bowel obstruction diagnosis.

Increased Attenuation of Intestinal Contents at CT Indicates Bowel Necrosis in Closed-Loop Small Bowel Obstruction

Background Preoperative recognition of irreversible bowel necrosis is important, as it provides valuable guidance for surgical strategy selection but also may inform perioperative risk assessment and communication. Few studies have focused on the association between CT signs and bowel necrosis. Purpose To assess the diagnostic accuracy of CT signs to predict bowel necrosis in patients with closed-loop small bowel obstruction (CL-SBO). Materials and Methods This retrospective single-center study included patients who were surgically confirmed to have CL-SBO caused by adhesion or internal hernia between January 2016 and May 2022. Necrosis was determined based on surgical exploration and postoperative pathologic examination. Two radiologists independently reviewed CT signs by both subjective visual assessment and objective measurement. Disagreements were resolved in consensus with a third gastrointestinal radiologist. Univariable and multivariable analyses were used to assess the association between CT signs and bowel necrosis, and Cohen κ was used to assess interobserver agreement. Sensitivity and specificity were calculated for each CT sign. Results This study included 145 patients: 61 (42.1%) in the necrotic group (median age, 62 years [IQR, 51-71.5 years]; 37 [60.7%] women) and 84 (57.9%) in the nonnecrotic group (median age, 61.5 years [IQR, 51-68.8 years]; 51 [60.7%] women). Univariable analysis and multivariable analysis showed that increased attenuation of intestinal contents and increased attenuation of intestinal wall were independent predictors for bowel necrosis (odds ratio = 45.3 and 15.1; P = .001 and P < .001, respectively). Increased attenuation of intestinal contents and increased attenuation of intestinal wall had similar sensitivity (64% and 67%, respectively) and specificity (99% and 92%, respectively) for predicting bowel necrosis. However, interobserver agreement was better for assessing the contents than the wall (κ = 0.84 and 0.59, respectively). Conclusion Increased attenuation of intestinal contents was a highly specific CT sign with good reproducibility to predict bowel necrosis in CL-SBO. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Taourel and Zins in this issue.

A 'traumatic' mechanical small bowel obstruction after blunt pelvic trauma

Traumatic abdominal wall hernia (TAWH) is a rare form of herniation caused by blunt trauma that can lead to intestinal obstruction. This report details a rare case of delayed mechanical ileus resulting from TAWH due to an acetabular fracture. The patient was successfully treated with laparoscopic closure of the peritoneal orifice, followed by orthopaedic repair of the fracture. The presented scenario underlines the importance of timely diagnosis and interdisciplinary collaboration in addressing complex TAWH cases.

Primary Midgut Volvulus: An Unusual Case of a Young Adult Necessitating Extensive Bowel Resection

Primary small bowel volvulus (SBV), commonly known as midgut volvulus, is an uncommon condition in which the small intestine rotates around its own mesenteric axis. This case report details the diagnostic and management challenges encountered in a rare presentation of primary SBV in a previously healthy 19-year-old male. Our patient presented with acute abdominal pain, vomiting, and signs of shock, prompting urgent medical attention. He was sent for exploratory laparotomy and underwent extensive resection of the gangrenous bowel. Diagnosis involved an abdominal computed tomography scan revealing the characteristic "whirl sign." According to the World Society of Emergency Medicine, surgical intervention should be done to address the SBV through resection of the gangrenous bowel segments. Despite efforts, the patient's prognosis remained guarded, necessitating ongoing supportive measures. This case highlights the complex challenges associated with primary SBV, emphasizing the need for continued research to enhance diagnostic precision and refine management strategies.

Clinical application of super-low-positioned intestinal decompression tube in the treatment of intestinal obstruction: a pilot study

OBJECTIVE

This study aimed to evaluate the clinical application and efficacy of a super-low-positioned intestinal decompression tube in the treatment of intestinal obstruction.

METHODS

A total of 130 patients with postoperative small bowel obstruction were included in this study. The patients were divided into a super-low-positioned intestinal decompression group and a conventional intestinal decompression group. The clinical data, treatment outcomes, and complications were compared between the two groups.

RESULTS

The technical success rate of placing the super-low-positioned intestinal decompression tube was 100%, with no intraoperative complications. The patients in the super-low-positioned intestinal decompression group had a significantly shorter hospital stay (8.3 ± 5.2 vs 17.7 ± 13.3, P < 0.001) and a higher non-operative treatment success rate (83.6% vs 57.9%, P = 0.001) compared to the conventional intestinal decompression group. Multivariate logistic regression analysis showed that the placement of a super-low-positioned intestinal decompression tube was an independent protective factor for treatment outcomes (P = 0.001). The hospital stay was significantly shorter in the super-low-positioned intestinal decompression group compared to the conventional group in both successful non-operative treatment patients (6.9 ± 3.0 vs 11.2 ± 7.5, P < 0.001) and failed non-operative treatment patients (16.2 ± 7.4 vs 26.6 ± 14.4, P < 0.001). The super-low-positioned intestinal decompression tube effectively relieved the "Self-strangulation" phenomenon in patients with intestinal obstruction.

CONCLUSION

The super-low-positioned intestinal decompression tube is a safe and effective method for the treatment of intestinal obstruction, with better treatment outcomes and shorter hospital stays compared to conventional intestinal decompression. Further prospective studies are needed to validate these findings.

Abdominal Emergencies in Cancer Patients

Abdominal emergencies in cancer patients encompass a wide spectrum of oncologic conditions caused directly by malignancies, paraneoplastic syndromes, reactions to the chemotherapy or often represent the first clinical manifestation of an unknown malignancy. Not rarely, clinical symptoms are the tip of an iceberg. In this scenario, the radiologist is asked to exclude the cause responsible for the patient's symptoms, to suggest the best way to manage and to rule out the underlying malignancy. In this article, we discuss some of the most common abdominal oncological emergencies that may be encountered in an emergency department.

Rare Combination of Chyloperitoneum Secondary to Primary Small-Bowel Volvulus

Chylous ascites is the exudation from lymphatic content to the peritoneum and is a rare situation that mostly occurs following medical causes like neoplasms or cirrhosis. However, trauma to the lymphatic system due to compression by masses or altered anatomy can be a trigger too. We describe a rare combination of a primary small bowel volvulus in a young healthy adult causing chylous ascites. Obstruction caused by a primary small bowell volvulus can re-arrange the lymphatics anatomy increasing their flow pressure which can lead to rupture and leak. This is an emergent scenario that needs to be addressed quickly because of bowel ischaemia. CT scan is the gold standard to expedite diagnosis and go to surgical treatment. Although it can be an impactful finding, treatment of the cause behind chylous ascites results in complete resolution without any bowel resection.

Improving the Knowledge and Competency of UK Foundation Doctors in Nasogastric Tube Placement: A National Study

Objective This study aims to improve foundation doctors' knowledge of guidelines for confirming nasogastric (NG) tube position and to enhance their confidence and competency in NG tube placement. Methods A three-part educational approach was designed, which included an educational leaflet and allowed the assessment of a participant's knowledge of guidelines pertaining to NG tube positioning before and after education. This educational leaflet and accompanying pre- and post-learning assessments were distributed among NHS Foundation Trusts in the UK between January 2022 and June 2022. All participants were foundation doctors in the UK. Those who had entered further training after the completion of their foundation training, at the time of assessment distribution, were excluded. Results A total of 173 participants completed this assessment. We found a significant increase in confidence among participants following the education (p<0.05). There was also a significant improvement in objective knowledge of guidelines on NG tube position confirmation following education (p<0.05). Conclusions Current knowledge on NG tube positioning is lacking among foundation doctors, but this can be significantly improved with simple educational leaflets. Furthermore, many participants felt that more training is needed, and this topic should be included in an essential teaching program.

Small bowel obstruction due to congenital band in an adult: Radio-surgical correlation

Congenital band is a rare cause of bowel obstruction, most commonly occurring in childhood. We report a case of a young adult with no medical and surgical previous history who had symptoms of bowel obstruction evolving for 2 days. Computed tomography (CT) found an adhesive band causing a small bowel obstruction. An open laparotomy was performed, and the intraoperative findings were consistent with a congenital band compressing the ileum. Through this clinical case, we illustrate an uncommon cause of bowel obstruction and the interest of the CT for the management.

Adhesive small-bowel obstruction as a challenging complication of familial Mediterranean fever: A case-based review

Familial Mediterranean fever (FMF) is the most common inherited autoinflammatory disorder, characterized by recurrent and self-limiting episodes of fever and serosal inflammation. Recurrent serositis may rarely lead to the formation of adhesions in the peritoneum, which may result in mechanical bowel obstruction. The symptoms, such as abdominal pain and vomiting, may mimic typical FMF attacks, resulting in misdiagnosis and severe morbidity, including strangulation and intestinal necrosis. Physicians are generally aware of other complications associated with FMF but reports on peritoneal adhesions and intestinal obstruction in English-language literature are inadequate to increase clinicians' awareness. Therefore, it is crucial to meticulously evaluate FMF patients presenting with abdominal pain and ileus because these symptoms could be due to adhesive small-bowel obstruction (ASBO). Furthermore, patients presenting with ASBO without a history of abdominal surgery should also be thoroughly evaluated, especially as it could be an initial presentation for an autoinflammatory disease. Herein, we present a pediatric case of FMF with the M694V homozygous mutation, complicated by ASBO while under colchicine treatment. Additionally, we provide a comprehensive review of the available literature on ASBO in FMF.

Meckel's diverticulum: analysis of 27 cases in an adult population

Background

Meckel's diverticulum is a rare congenital pathology among newborns. Nevertheless, it is an uncommon abdominal pathology in the adult population. Therefore, we aim to provide a detailed account of our surgical approach in treating 27 cases of Meckel's diverticulum.

Methods

This study is a cross-sectional analysis that utilized a database with prospectively collected data from 2004 to 2022. All patients under the age of 18 were excluded from the population. We described the population's demographic characteristics, symptoms, anatomopathological study, surgical technique, complications, morbidity, and mortality. A subgroup analysis was performed between the symptomatic and asymptomatic patients.

Results

A total of 27 patients who underwent surgical resection for a posteriorly diagnosed Meckel's diverticulum were included. The male population accounted for 81.4% (n = 22) of the sample size. The symptomatic group consisted of 18 male and four female patients. Abdominal pain was the predominant symptom in 85% of the patients. Out of the 22 symptomatic patients, only 9% had a positive perioperative diagnosis of Meckel's diverticulum. All 27 patients with diverticulum diagnosis received the resection through diverticulectomy (n = 6), small bowel resection with end-to-end anastomosis (n = 6), and small bowel resection with lateral to lateral anastomosis (n = 15). The mean distance between the diverticulum and the ileocecal valve was 63.4 cm. The symptomatic group had an average diverticulum length of 3.54 cm, with an average base width of 2.47 cm. In the other group, the values were 2.75 and 1.61 cm. The average length of hospital stay in the symptomatic group was 7.3 days.

Conclusions

Meckel's diverticulum is a rare pathology in the adult population. Its presentation varies from asymptomatic to symptomatic patients, and surgery is the cornerstone treatment for this pathology.

Case report: Rupture of an ileus tube in a patient with recurrent rectal cancer

The insertion of an ileus tube is an important treatment for intestinal obstruction. According to previous reports, jejunal intussusception has been reported as a complication associated with ileus tube placement. However, rupture of the weighted tip of an ileus tube has not been reported before. Herein, we report a 55-year-old Chinese woman who underwent radical proctectomy (DIXON) for rectal cancer and developed pelvic recurrence and lung metastasis 65 months after surgery, accompanied by symptoms of acute intestinal obstruction. An ileus tube was inserted before the operation (extensive total hysterectomy, bilateral adnexal resection, rectal Hartman operation, partial enterectomy, and intestinal adhesion lysis). Rupture of the ileus tube occurred after the operation and was treated with paraffin oil and enteral nutrition, and the metal beads and spring were eliminated through the colostomy. During the follow-up, the patient received targeted therapy plus immunotherapy, which was successful: the quality of life of the patient was excellent, and no obvious abnormal symptoms were found. Endoscopy-assisted ileus tube insertion should be performed under intravenous anesthesia, and a knot should be tied at the tip of the ileus tube before insertion so that the ileus tube can be inserted easily by grasping the thread with biopsy forceps(the "thread-knotting" method). With the above methods, the procedure of ileus tube insertion could be improved to reduce the incidence of tube-related rupture.

Small Bowel Obstruction in Virgin Abdomen: Predictors of Surgical Intervention Need in Resource-Limited Setting

Background

Limited evidence is available regarding the management of small bowel obstruction in the virgin abdomen (SBO-VA), with most studies excluding this entity. This study aims to assess the available data on the treatment outcomes and predictors of surgical intervention in SBO-VA.

Methods

A retrospective cross-sectional study was conducted between 2015 and 2021, including all diagnosed and managed cases of SBO-VA at Al-Nasar Hospital. Patients were divided according to the treatment approach into surgical or conservative groups. Preoperative laboratory and radiologic data were gathered and compared between groups.

Results

During the study period, 67 cases, primarily males (58.2%), with an average age of 52.2±14.4 years were assessed. Common comorbidities included diabetes (20.9%) and hypertension (16.4%). Key symptoms were rebound tenderness (82.1%) and abdominal tenderness (70.1%). The predominant etiology was adhesions (23.9%). About 46.2% received conservative treatment, 53.8% underwent urgent surgery. Conservative treatment failed in 9.4% of cases, and complications arose in 23.9%, with most being fever (17.9%). Factors necessitating surgical management included older age (58.8 ±11.7 vs 44.9 ±13.8 years, p<0.001), previous hospital admission (p<0.001), presence of abdominal tenderness (p=0.030), longer abdominal pain duration (4.0 ±0.9 vs 2.1 ±0.6 days, p<0.001), higher C- reactive protein (p= 0.033), higher white blood cell (p= 0.006), longer time to hospital presentation (75.3 ±17.2 vs 39.0 ±22.8 days, p= <0.001), small bowel thickness ≥3 cm (p=0.009), and reduced bowel enhancement (p <0.001) on computed tomography imaging. In surgical group, the need for ICU admission was higher and hospital stays were shorter than in conservative group and were statistically significant (p<0.05).

Conclusion

The main etiology of SBO-VA in our study was adhesions. Older age, previous hospital admission, longer abdominal pain duration, abdominal tenderness, increased inflammatory markers, and alarm signs on CT scans are the main factors for determining the need for urgent surgical exploration in patients with SBO-VA. To achieve prompt identification and intervention, it is crucial to maintain a high level of vigilance and awareness, even in individuals with no prior surgical history.

THE WATER-SOLUBLE CONTRAST FOR ADHESIVE SMALL BOWEL OBSTRUCTION: ARE THERE ADVANTAGES?

BACKGROUND

Adhesive small bowel obstruction is one of the most common causes of surgical emergencies, representing about 15% of hospital admissions. Defining the need and timing of surgical intervention still remains a challenge.

AIMS

To report the experience of using meglumine-based water-soluble contrast in a tertiary hospital in southern Brazil, comparing with the world literature.

METHODS

Patients suspected of having adhesive small bowel obstruction, according to their clinical conditions, underwent an established protocol, consisting of the administration of water-soluble contrast, followed by plain abdominal radiograph within 12 hours and by a new clinical evaluation. The protocol was initiated after starting conservative management, including fasting and placement of a nasogastric tube, as well as intravenous fluid reposition.

RESULTS

A total of 126 patients were submitted to the protocol. The water-soluble contrast test sensitivity and specificity after the first radiograph were 94.6 and 91.0%, respectively; after the second radiograph, these values were 92.3 and 100%. The general test values for sensitivity and specificity were 91.9 and 100%, respectively.

CONCLUSIONS

The measure parameters evaluated in this study were similar to those found in the literature, contributing to endorse the importance of this test in the evaluation of patients with adhesive small bowel obstruction. The particular relevance of this study was the similar results that were found using a different type of meglumine-based contrast, which is available in Brazil.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Gastric, Duodenal, and Small Bowel Emergencies

Gastric and small bowel emergencies are often seen in the emergency department and require rapid assessment and intervention as patients can deteriorate quickly. Some of the more frequently seen gastric emergencies include gastric volvulus and peptic ulcer disease, which can present with ischemia, strangulation, perforation, or severe bleeding. Swift diagnosis is crucial to ensuring the proper management whether that is endoscopic or with surgical exploration. Perforated peptic ulcers that are not contained will require surgical intervention, whereas bleeding ulcers can often be controlled with endoscopic interventions.

Survey of Diagnostic and Management Practices in Small Bowel Obstruction: Individual and Generational Variation Despite Practice Guidelines

Background: Small bowel obstruction (SBO) is a common disorder managed by surgeons. Despite extensive publications and management guidelines, there is no universally accepted approach to its diagnosis and management. We conducted a survey of acute care surgeons to elucidate their SBO practice patterns.Methods: A self-report survey of SBO diagnosis and management practices was designed and distributed by email to AAST surgeons who cared for adult SBO patients. Responses were analyzed with descriptive statistics and Chi-square test of independence at α = .05.Results: There were 201 useable surveys: 53% ≥ 50 years, 77% male, 77% at level I trauma centers. Only 35.8% reported formal hospital SBO management guidelines. Computed tomography (CT) scan was the only diagnostic exam listed as "essential" by the majority of respondents (82.6%). Following NG decompression, 153 (76.1%) would "always/frequently" administer a water-soluble contrast challenge (GC). There were notable age differences in approach. Compared to those ≥50 years, younger surgeons were less likely to deem plain abdominal films as "essential" (16.0% vs 40.2%; P < .01) but more likely to require CT scan (88.3% vs 77.6%; P = .045) for diagnosis and to "always/frequently" administer GC (84.0% vs 69.2%; P < .01). Younger surgeons used laparoscopy "frequently" more often than older surgeons (34.0% vs 21.5%, P = .05).Discussion: There is significant variation in diagnosis and management of SBO among respondents in this convenience sample, despite existing PMGs. Novel age differences in responses were observed, which prompts further evaluation. Additional research is needed to determine whether variation in practice patterns is widespread and affects outcomes.

Optimal Time to Surgery for Small Bowel Obstruction: A Risk Adjusted Analysis Utilizing the Nationwide Inpatient Sample

BACKGROUND

The management of a small bowel obstruction (SBO) remains a challenge for general surgeons. The majority of SBOs can be treated conservatively; however, when surgery is required, the timing of operative intervention remains uncertain. Utilizing a large national database, we sought to evaluate the optimal timeframe for surgery following hospital admission with a diagnosis of SBO.

METHODS

This was a retrospective review utilizing the Nationwide Inpatient Sample (2006-2015). Outcomes following surgery for SBO were identified using ICD-9-CM coding. Two comorbidity indices were utilized to determine severity of illness. Patients were stratified into four groups based on time in days from admission to surgery. Propensity score models were created to predict the number of days until surgery following admission. Multivariate regression analysis was performed to determine risk adjusted postoperative outcomes.

RESULTS

We identified 92 807 cases of non-elective surgery for SBO. The overall mortality rate was 4.7%. Surgery on days 3-5 was associated with the lowest rate of mortality. A longer preoperative length of stay (LOS) (3-5 days) was associated with a significantly greater number of wound (OR = 1.24) and procedural (OR = 1.17) complications compared to day 0. However, delayed surgical intervention (≥6 days) was associated with decreased cardiac (OR = .69) and pulmonary complications (OR = .58).

DISCUSSION

After adjustment, a preoperative LOS of 3-5 days was associated with a decreased risk of mortality. In addition, increasing preoperative LOS was associated with decreased cardiopulmonary complications. However, an increased risk of procedural and wound complications during this time period suggest surgery may be more technically challenging.

Safety and feasibility of robotic surgery for colon cancer patients with previous abdominal surgery: a propensity score-matching analysis

Robotic surgery is widely used in gastrointestinal surgery. While the application of robotic surgery for colon cancer patients with previous abdominal surgery (PAS) remains controversial for the fear of intra-abdominal adhesions. This study was aimed to evaluate the safety and feasibility of robotic colectomy for patients with PAS. The medical records of colon cancer patients who underwent robotic surgery at our hospital from June 2015 to August 2020 were extracted and analyzed. Propensity score-matching (PSM) analysis was implemented to minimize selection bias. We compared perioperative outcomes and postoperative complications between the patients with PAS or with no PAS (NPAS). A total of 79 patients (PAS group) and 348 patients (NPAS group) were included in our study. After PSM, 79 patients of PAS group and 79 patients of NPAS group were selected for further analysis. We did not find statistical difference in operative time, estimated blood loss, lymph nodes retrieved, length of hospital stay and hospital costs between the two groups. No difference was noted in the incidence of postoperative complications, conversion to open surgery and mortality between the two groups. According to the results of multivariate analysis, PAS was not identified as risk factor for postoperative complications. Left hemicolectomy and perioperative transfusion were associated with postoperative complications. PAS did not negatively affect the outcomes of robotic colectomy. After individually preoperative assessment, robotic surgery could be performed feasibly and safely for colon cancer patients with PAS.

Trends in Management of Index Adhesive Small Bowel Obstruction in Children

INTRODUCTION

To examine practice patterns and surgical outcomes of nonoperative versus operative management (OPM) of children presenting with an index adhesive small bowel obstruction (ASBO).

METHODS

A California statewide health discharge database was used to identify children (<18 y old) with an index ASBO from 2007 to 2020. The primary study outcome was evaluating initial management patterns (nonoperative versus OPM and early [≤3 d] versus late surgery [>3 d]) of ASBO. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications.

RESULTS

Of the 2297 patients identified, 1948 (85%) underwent OPM for ASBO during the index admission. Of these, 14.7% underwent early surgery within 3 d. Teaching hospitals had higher operative intervention than nonteaching centers (87.1% versus 83.7%, P = 0.034). OPM was the highest in 0-5-year-olds compared to other ages (89% versus 82%, P < 0.001). In comparison to early surgery, late surgery was associated with longer length of stay (early 7[interquartile range 5-10], late 9[interquartile range 6-17], P < 0.001), increased infectious complications (16.4% versus 9.8%, P = 0.004), and greater use of total parenteral nutrition (28.0% versus 14.3%, P = 0.001); there was no difference in bowel resection (21% versus 18%, P = 0.102) or mortality (P = 0.423).

CONCLUSIONS

Our pediatric study demonstrated a high rate of OPM for index ASBO, especially in newborns and toddlers. Although operative intervention, especially late surgery, was associated with increased length of stay, increased infectious complications, and increased total parenteral nutrition use, the rates of bowel resection and mortality did not differ by management strategy. These trends need to be further evaluated to optimize outcomes.

Chronic constipation and acute small bowel obstruction due to small bowel encapsulation: A case report

Key Clinical Message

Peritoneal encapsulation is most of the time asymptomatic and is found incidentally, but when symptomatic it usually presents with bowel obstruction. CT scan is a gold standard for the diagnosis of bowel encapsulation.

Abstract

Congenital peritoneal encapsulation (CPE), abdominal cocoon syndrome (ACS), and sclerosing encapsulating peritonitis (SEP) are syndromes in which the small bowel is encapsulated. Small bowel encapsulation is usually asymptomatic and rarely presents with small bowel obstruction. In this article, we report a 65-year-old man who presented to our hospital with signs and symptoms of small bowel obstruction. He underwent an urgent operation, and small bowel encapsulation was diagnosed. One year after the surgery, all symptoms improved.

Clinical Indicators to Determine the Timing of Surgery for Adhesive Small Bowel Obstruction

BACKGROUND

Decompression of the intestine with a long tube or nasogastric tube is the first-choice treatment for adhesive small bowel obstruction (ASBO). Scheduling surgery while weighing the risks of surgery against conservative care is a crucial factor in clinical decision-making. Whenever feasible, unnecessary surgeries should be avoided, and it is essential to provide clinical markers for this. This study aimed to obtain evidence regarding the optimal timing of ASBO and when conservative treatment options are not successful.

METHODS

The data of patients diagnosed with ASBO and receiving long tube insertion for more than 7 days were reviewed. We investigated transit ileal drainage volume and recurrence. The primary outcomes were the change in the drainage volume from the long tube over time and the percentage of patients who required surgery. We evaluated some cutoff values to determine the indication for surgery based on the insertion duration and volume of long tube drainage.

RESULTS

Ninety-nine patients were enrolled in this study. Fifty-one patients showed improvement with conservative treatment, whereas 48 ultimately required surgery. When a daily drainage volume of ≥500 mL was considered an indication for surgery, 13-37 cases (25%-72%) would be judged unnecessary within 6 days of long tube insertion, while 5 cases (9.8%) would be judged unnecessary on day 7.

DISCUSSION

Unnecessary surgical interventions for ASBO might be avoided by assessing the drainage volume on day 7 after inserting a long tube.

Multifunctional calcium polyphenol networks reverse the hostile microenvironment of trauma for preventing postoperative peritoneal adhesions

Abdominal adhesions, a commonly observed complication of abdominal surgery, have a high incidence and adversely affect patients' physical and mental health. The primary causes of abdominal adhesions are intraoperative trauma, acute inflammatory response, bleeding, and foreign body infection. Because most current treatment approaches for abdominal adhesions are limited, improved and novel postoperative anti-adhesion regimens are urgently needed. In this study, we developed calcium polyphenol network (CaPN) microspheres based on the self-assembly of the natural triphenolic compound gallic acid and Ca2+ in solution. The physicochemical properties of CaPNs, including their hemostatic, antibacterial, antioxidant, and anti-inflammatory activities, were investigated in vitro. Bleeding and cecal-abdominal wall adhesion models were established to observe the hemostatic activity of CaPNs and their preventive effect on postoperative abdominal wall adhesion in vivo. The results showed that CaPNs significantly reduced inflammation, oxidative stress, fibrosis, and abdominal adhesion formation and had good hemostatic and antibacterial properties. Our findings suggest a novel strategy for the prevention of postoperative adhesions.

Laparoscopic adhesiolysis versus open adhesiolysis in acute adhesive small bowel obstruction

Introduction

Exploratory laparotomy is still the standard therapy for patients who need surgical intervention for adhesive small bowel obstruction (SBO). However, the use of laparoscopy in the management of adhesive SBO is still controversial. We aimed to detect the short-term outcomes between open and laparoscopic adhesiolysis for SBO.

Patients and Methods

This is a retrospective study of patients with adhesive SBO who underwent either laparoscopic or open surgery from June 2019 to July 2022 at Ain Shams University Hospitals. Intraoperative and early post-operative outcomes were compared in the two groups.

Results

A total of 89 patients with adhesive SBO were included in our study. Fifty-one cases underwent open adhesiolysis and 38 cases underwent laparoscopic adhesiolysis. Laparoscopic adhesiolysis is associated with a remarkable decrease in the operative time (71 min vs. 107 min, P = 0.001) and blood loss (50 ml vs. 120 ml, P = 0.001) in comparison to open adhesiolysis. In addition to that, those who underwent adhesiolysis by laparoscopy had a short hospital stay (2.4 days vs. 3.8 days, P = 0.001), early recovery (time to pass flatus 1.3 days vs. 2.8 days) and less post-operative complications (surgical site infection [SSI] 2.6% vs. 19.6%, P = 0.001). Moreover, open adhesiolysis is associated with a higher rate of early post-operative mortality. In addition to that, the incidence of iatrogenic injury was higher in the open group.

Conclusion

Laparoscopic adhesiolysis is a safe and feasible approach for the management of SBO and has better short-term outcomes, especially if done by skilled surgeons in advanced laparoscopic techniques.

The Clinical Frailty Scale (CFS) as an Independent Prognostic Factor for Patients ≥80 Years with Small Bowel Obstruction (SBO)

BACKGROUND

SBO is a potentially life-threatening condition that often affects older patients. Frailty, more than age, is expected to play a crucial role in predicting SBO prognosis in this population. This study aims to define the influence of Clinical Frailty Scale (CFS) on mortality and major complications in patients ≥80 years with diagnosis of SBO at the emergency department (ED).

METHODS

All patients aged ≥80 years admitted to our ED for SBO from January 2015 to September 2020 were enrolled. Frailty was assessed through the CFS, and then analyzed both as a continuous and a dichotomous variable. The endpoints were in-hospital mortality and major complications.

RESULTS

A total of 424 patients were enrolled. Higher mortality (20.8% vs 8.6%, p<0.001), longer hospital stay (9 [range 5-14] days vs 7 [range 4-12] days, p=0.014), and higher rate of major complications (29.9% vs 17.9%, p=0.004) were associated with CFS ≥7. CFS score and bloodstream infection were the only independent prognostic factors for mortality (OR 1.72 [CI: 1.29-2.29], p<0.001; OR 4.69 [CI: 1.74-12.6], p=0.002, respectively). Furthermore, CFS score, male sex and surgery were predictive factors for major complications (OR 1.41 [CI: 1.13-1.75], p=0.002; OR 1.67 [CI: 1.03-2.71], p=0.038); OR 1.91 [CI: 1.17-3.12], p=0.01; respectively). At multivariate analysis, for every 1-point increase in CFS score, the odds of mortality and the odds of major complications increased 1.72-fold and 1.41-fold, respectively.

CONCLUSION

The increase in CFS is directly associated with an increased risk of mortality and major complications. The presence of severe frailty could effectively predict an increased risk of in-hospital death regardless of the treatment administered. The employment of CFS in elderly patients could help the identification of the need for closer monitoring and proper goals of care.

A multi-analysis of nomogram model for the identification of banded adhesions and matted adhesions in adhesive small bowel obstruction

BACKGROUND

Preoperative diagnosis of the cause of adhesive small bowel obstruction (ASBO) is very challenging for surgeons. We aimed to develop a nomogram model for the identification of banded adhesions (BA) and matted adhesions (MA) of ASBO.

METHODS

This retrospective study enrolled patients with ASBO between January 2012 and December 2020, classified into BA and MA groups according to the intraoperative findings. A nomogram model was developed by using multivariable logistic regression analysis.

RESULTS

A total of 199 patients were included, with 117 (58.8%) cases of BA and 82 (41.2%) cases of MA. There were 150 patients designed for training the model, and the other 49 cases for validation. Multivariate logistic regression analysis showed that prior surgery for once (p = 0.008), white blood cells (WBC) (p = 0.001), beak sign (p < 0.001), fat notch sign (p = 0.013), and mesenteric haziness (p = 0.005) were independently associated with BA. The AREA under the receiver operating characteristic curve (AUC-ROC) of the nomogram model in the training and validation sets were 0.861 (95% CI 0.802-0.921) and 0.884 (95% CI 0.789-0.980), respectively. The calibration plot demonstrated a good agreement. A decision curve analysis demonstrated that the nomogram model was clinically useful.

CONCLUSIONS

The multi-analysis of the nomogram model might have a favorable clinical applicability for the identification of BA and MA in patients with adhesive small bowel obstruction.

Predictive markers in estimating the need for early intensive care in patients with adhesive small bowel obstruction in the emergency department

Introduction

Adhesive small-bowel obstruction (ASBO) is a common condition requiring emergency room admission, and predicting the need for intensive care unit (ICU) hospitalisation is crucial for optimal patient management. This study aimed to investigate the predictive value of various scores and indices in determining ICU requirements in patients with ASBO.

Patients and Methods

Seventy patients diagnosed with ASBO and managed nonoperatively were included in the study. Data on patient demographics, laboratory values, imaging findings, previous hospitalisations and comorbidities were collected. The Sequential Organ Failure Assessment (SOFA) score, Charlson Comorbidity Index (CCI) score and C-reactive protein (CRP)/albumin ratio were calculated. Patients were categorised into ICU and non-ICU groups for analysis.

Results

The ICU group comprised patients with higher number of previous ASBO hospitalisations and longer hospitalisation days. Serum albumin levels were significantly lower and the maximum small-bowel horizontal diameter was significantly higher in the ICU group. The SOFA score and CCI score were significantly higher in the ICU group. The CRP/albumin ratio showed a trend towards significance.

Conclusion

The number of days since the last stool discharge, SOFA score and CCI score demonstrated significant associations with ICU requirements in ASBO patients. These findings highlight the importance of assessing organ dysfunction, comorbidities and gastrointestinal function during patient triage. Our study provides valuable insights into predicting ICU need in ASBO patients, aiding in resource allocation and patient management.

An obscure cause of bowel obstruction: Jejunal herniation into uterine cavity

INTRODUCTION AND IMPORTANCE

Adhesions and external hernias are the two most common causes of small bowel obstruction. Perforation of organs within the abdomen or pelvis following manual vacuum aspiration is known to lead to an acute presentation.

CASE PRESENTATION

We report a case of a 33-year-old female with small bowel obstruction due to herniation of a loop of intestine through a uterine defect with symptoms starting 63 days following manual vacuum aspiration.

CLINICAL DISCUSSION

Intra-abdominal or pelvic perforations usually present immediately which makes our case unique as the patient started having symptoms 63 days post manual vacuum aspiration. The most feared complication of prolonged small bowel obstruction is ischaemia which may lead to perforation. In our case, it is plausible that jejunum partially herniated into the uterine cavity shortly after manual vacuum aspiration, forming a jejunal plug, leading to the delayed onset of symptoms. This delay in onset of symptoms might have led to progressive massive dilatation of the small bowel and subsequent ischaemic necrosis.

CONCLUSION

Detailed history taking is pertinent as bowel obstruction could still occur a prolonged period after manual vacuum aspiration. A double-contrast enhanced CT scan of the abdomen proves invaluable in the context of surgical planning and facilitating the collaboration of a multidisciplinary team, particularly when the underlying causes of bowel obstruction remain elusive upon initial presentation.

Current status of laparoscopic emergency surgery in Korea: multicenter restrospective cohort study

Purpose

Laparoscopic surgery is a choice in several emergency settings. However, there has been no nationwide study or survey that has compared the clinical use of laparoscopic emergency surgery (LES) versus open abdominal emergency surgery (OES) in Korea. Therefore, we examined the state of LES across multiple centers in Korea and further compared this data with the global state based on published reports.

Methods

Data of 2,122 patients who received abdominal emergency surgery between 2014 and 2019 in three hospitals in Korea were collected and retrospectively analyzed. Several clinical factors were investigated and analyzed.

Results

Of the patients, 1,280 (60.3%) were in the OES group and 842 (39.7%) were in the LES group. The most commonly operated organ in OES was the small bowel (25.8%), whereas that for LES was the appendix. In appendectomy and cholecystectomy, 93.7% and 88.0% were in the LES group. In small bowel surgery, gastric surgery, and large bowel surgery, 89.4%, 92.0%, and 79.1% were in the OES group. The severity-related factors of patient status demonstrated statistically significant limiting factors of selection between LES and OES.

Conclusion

Although our study has several limitations, compared to the LES data from other countries, the general LES state was similar in appendectomies, cholecystectomies, and small bowel surgeries. However, in gastric and colorectal surgeries, the LES state was different from those of other countries. This study demonstrated the LES state and limiting factors of selection between LES and OES in various operated organs. Further studies are required to analyze these differences and the various limiting factors.

One-year outcomes following operative or non-operative management of adhesional small bowel obstruction

BACKGROUND

A trial of initial non-operative management is recommended in stable patients with adhesional small bowel obstruction. However, recent retrospective studies have suggested that early operative management may be of benefit in reducing subsequent recurrences. This study aimed to compare recurrence rates and survival in patients with adhesional small bowel obstruction treated operatively or non-operatively.

METHODS

This was a prospective cohort study conducted at six acute hospitals in Denmark, including consecutive patients admitted with adhesional small bowel obstruction over a 4-month interval. Patients were stratified into two groups according to their treatment (operative versus non-operative) and followed up for 1 year after their index admission. Primary outcomes were recurrence of small bowel obstruction and overall survival within 1 year of index admission.

RESULTS

A total of 201 patients were included, 118 (58.7 per cent) of whom were treated operatively during their index admission. Patients undergoing operative treatment had significantly better 1-year recurrence-free survival compared with patients managed non-operatively (operative 92.5 per cent versus non-operative 66.6 per cent, P <0.001). However, when the length of index admission was taken into account, patients treated non-operatively spent significantly less time admitted to hospital in the first year (median 3 days non-operative versus 6 days operative, P <0.001). On multivariable analysis, operative treatment was associated with decreased risks of recurrence (HR 0.22 (95 per cent c.i. 0.10-0.48), P <0.001) but an increased all-cause mortality rate (HR 2.48 (95 per cent c.i. 1.13-5.46), P = 0.024).

CONCLUSION

Operative treatment of adhesional small bowel obstruction is associated with reduced risks of recurrence but increased risk of death in the first year after admission.

REGISTRATION NUMBER

NCT04750811 (http://www.clinicaltrials.gov).prior (registration date: 11 February 2021).

Management of adhesive small bowel obstruction: the results of a large retrospective study

BACKGROUND

Postoperative adhesive small bowel obstruction (SBO) is a frequent cause of hospital admission in a surgical department. Emergency surgery is needed in a majority of patients with bowel ischemia or peritonitis; most adhesive SBO can be managed nonoperatively. Many studies have investigated benefits of using oral water-soluble contrast to manage adhesive SBO. Treatment recommendations are still controversial.

METHODS

We conducted an observational retrospective monocentric study to test our protocol of management of SBO using Gastrografin®, enrolling 661 patients from January 2008 to December 2021. An emergency surgery was performed in patients with abdominal tenderness, peritonitis, hemodynamic instability, major acute abdominal pain despite gastric decompression, or CT scan findings of small bowel ischemia. Nonoperative management was proposed to patients who did not need emergency surgery. A gastric decompression with a nasogastric tube was immediately performed in the emergency room for four hours, then the nasogastric tube was clamped and 100 ml of nondiluted oral Gastrografin® was administered. The nasogastric tube remained clamped for eight hours and an abdominal plain radiograph was taken after that period. Emergency surgery was then performed in patients who had persistent abdominal pain, onset of abdominal tenderness or vomiting during the clamping test, or if the abdominal plain radiograph did not show contrast product in the colon or the rectum. In other cases, the nasogastric tube was removed and a progressive refeeding was introduced, starting with liquid diet.

RESULTS

Seventy-eight percent of patients with SBO were managed nonoperatively, including 183 (36.0%) who finally required surgery. Delayed surgery showed a complete small bowel obstruction in all patients who failed the conservative treatment, and a small bowel resection was necessary in 19 patients (10.0%): among them, only 5 had intestinal ischemia.

CONCLUSIONS

Our protocol is safe, and it is a valuable strategy in order to accelerate the decision-making process for management of adhesive SBO, with a percentage of risk of late small bowel resection for ischemia esteemed at 0.9%.

Association between clinical and surgical variables with postoperative outcomes in patients treated for intestinal obstruction for non-malignant conditions: a cross-sectional study

Intestinal obstruction is considered a frequent surgical pathology related to previous surgical procedures. Many different factors can lead to different outcomes when surgical management is needed. Therefore, we aim to describe the factors related to morbidity and mortality in surgical management of IO in a single-center experience. Retrospective observational study with a prospective database, in which we described patients who underwent surgical management due to intestinal obstruction between 2004 and 2015. Demographics, perioperative data, surgical outcomes, morbidity, and mortality were described. 366 patients were included. Female were 54.6%. Mean age was 61.26. Laparoscopic approach was done in 21.8% and the conversion rate was 17.2%. Intestinal resection was performed in 37.9% of the cases. Postoperative complications were observed in 18.85%. Reintervention and mortality were 9.5% and 4.1% respectively. Laparoscopic approach shows lesser time of intestinal transit (mean 28.67 vs. mean 41.95 h), and restart of oral intake after surgery (mean 96.06 vs. mean 119.65) compared with open approach. Increased heart rate and intensive care unit length of stay were related with mortality (p 0.01 and 0.000 respectively). For morbidity, laparotomy and need and duration of ICU stay were related with any complication statistically significant (p 0.02, 0.008, 0.000 respectively). Patients with increased heart rate in the emergency room, decreased amount of intravenous fluids, need and higher length of stay in the intensive care unit, and delay in resuming oral intake after surgery appear to have poor outcomes. Laparoscopic approach seems to be a safe and feasible approach for intestinal obstruction in selected patients.

Individualization of the best approach for adhesive small bowel obstruction

BACKGROUND

Laparoscopic postoperatives outcomes in adhesiolysis are promising but conversion and morbidity remains high. The objective of our study was to determine preoperative factors to individualize and select the most appropriate approach for each patient.

METHODS

Patients ≥18 years old undergoing emergent surgery for adhesive small bowel obstruction and internal hernias were evaluated. Bivariate and multivariate analysis were performed to investigate factors related to conversion to open surgery and to the type of adhesions.

RESULTS

Of 333 patients, 224 were operated by laparotomy and 109 by laparoscopy (conversion rate: 40%). Previous abdominal wall mesh, type of adhesions, bowel lesion, need for intestinal resection and laparoscopic skills were statistically related to conversion. In the multivariate analysis, complex adhesions (OR 4.3, 95% CI 1.5-12.2; P = 0.006), the need for intestinal resection (OR 14.16, 95% CI 2.55-78.68; P = 0.002), and non-advanced laparoscopy surgeons (OR 4.31, 95% CI 1.56-11.94; P = 0.005) were independent factors for conversion to open surgery. ASA III-IV, previous surgeries, previous abdominal mesh and previous adhesiolysis were related to complex adhesions. Previous laparoscopic surgery and internal hernia or closed loop in computed tomography were associated with simple adhesions as a cause of the obstruction. In the multivariate, previous adhesiolysis (OR 4.76, 95% CI 1.23-18.3; P = 0.023) and the findings on computed tomography were significantly related with the type of adhesion.

CONCLUSION

Some preoperative factors allow to individualize the surgical approach in the adhesive small bowel obstruction improving surgical outcomes.