1
|
Lin SW, Chen CY, Chen PC, Feng CL, Lin HY, Chen JH. 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. Surg Endosc 2024:10.1007/s00464-024-10746-6. [PMID: 38453749 DOI: 10.1007/s00464-024-10746-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024]
Abstract
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.
Collapse
Affiliation(s)
- Shang-Wei Lin
- Division of Plastic Surgery, Department of Surgery, Cathay General Hospital, Taipei, 10630, Taiwan
- Department of Surgery, Cathay General Hospital, Taipei, 10630, Taiwan
| | - Chung-Yen Chen
- Division of General Surgery, Department of Surgery, E-Da Hospital, Kaohsiung, Taiwan
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Pin-Chun Chen
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Colon & Rectal Surgery, Department of Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Che-Lun Feng
- Division of General Surgery, Department of Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Hung-Yu Lin
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
- Division of Urology, Department of Surgery, E-Da Cancer & E-Da Hospital, Kaohsiung, Taiwan.
| | - Jian-Han Chen
- Division of General Surgery, Department of Surgery, E-Da Hospital, Kaohsiung, Taiwan.
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan.
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
| |
Collapse
|
2
|
Ali K, Cho NY, Vadlakonda A, Sakowitz S, Kim S, Chervu N, Hadaya J, Benharash P. Prior bariatric surgery is associated with lower mortality and resource utilization following small bowel obstruction. Surg Open Sci 2024; 18:85-90. [PMID: 38435488 PMCID: PMC10907194 DOI: 10.1016/j.sopen.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024] Open
Abstract
Background Small bowel obstruction (SBO) is a complication of bariatric surgery. However, outcomes of surgical intervention for SBO among patients with prior bariatric surgery remain ill-defined. We used a nationally representative cohort to characterize the outcomes of the SBO management approach in patients with a prior bariatric operation. Methods All adult hospitalizations for SBO were tabulated from the 2018-2020 National Readmissions Database. Patients with a prior history of bariatric surgery comprised the Bariatric cohort (others: Non-Bariatric). Multivariable models were subsequently developed to evaluate the association of prior bariatric surgery with outcomes of interest. Results Of an estimated 299,983 hospitalizations for SBO, 15,788 (5.3 %) had a history of prior bariatric surgery. Compared to Non-Bariatric, Bariatric patients were younger (54 [46-62] vs 57 [47-64] years, P < 0.001) and were more frequently privately insured (45.1 vs 39.4 %, P < 0.001). On average, the Bariatric more frequently underwent operative management, relative to Non-Bariatric (44.8 vs 29.7 %, P < 0.001). Following risk adjustment, among those surgically managed, Bariatric demonstrated lower odds of mortality (Adjusted Odds Ratio [AOR] 0.69, 95 % Confidence Interval [CI] 0.55-0.87) compared to Non-Bariatric. Bariatric also demonstrated lower odds of infectious and renal complications. Furthermore, the Bariatric cohort had lower costs, length of stay, and non-home discharge. Conclusions Patients with prior bariatric surgery demonstrated a lower likelihood of mortality, decreased complications, and reduced resource utilization, relative to others. As the incidence of bariatric surgery continues to rise, future work is needed to minimize the incidence of SBO among these patients, especially in the current era of value-based healthcare.
Collapse
Affiliation(s)
- Konmal Ali
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Nam Yong Cho
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Amulya Vadlakonda
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Sara Sakowitz
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Shineui Kim
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Nikhil Chervu
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Joseph Hadaya
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| |
Collapse
|
3
|
Kubiszewski K, Chapman RW, Piazza Y, Patel D, Neychev V. Hypothyroidism Presenting as Adynamic Ileus Mimicking a Mechanical Small Bowel Obstruction: A Diagnostic and Management Dilemma. Cureus 2023; 15:e50799. [PMID: 38239558 PMCID: PMC10796157 DOI: 10.7759/cureus.50799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 01/22/2024] Open
Abstract
Patients who present with nausea, vomiting, constipation, and abdominal pain typically undergo workups for small bowel obstruction (SBO). SBO is commonly caused by mechanical obstruction due to adhesions, inflammatory conditions, or malignancies. Hypothyroidism is primarily associated with decreased basal metabolic rate and rarely, in severe cases, gastrointestinal motility dysfunction. We report a case of a 44-year-old man who presented to the emergency department with abdominal pain, nausea, and vomiting. The workup, including computed tomography, showed a small bowel feces sign, highly suspicious for a mechanical SBO. His past medical history was significant for a poorly controlled hypothyroidism due to Hashimoto's thyroiditis with a markedly elevated thyroid stimulating hormone (TSH) level. He had no prior surgical history, and his family history was significant for a suspected inflammatory bowel disease (IBD) in his son. The patient failed initial resuscitative nonoperative management and underwent exploratory laparoscopy that revealed diffusely dilated small bowel loops with no obvious cause of mechanical obstruction. Inflammatory markers for IBD were found to be negative, and the patient's gastrointestinal motility gradually improved with daily intravenous levothyroxine.
Collapse
Affiliation(s)
- Kacper Kubiszewski
- Medical School, University of Central Florida College of Medicine, Orlando, USA
| | - Rachel W Chapman
- Medical School, University of Central Florida College of Medicine, Orlando, USA
| | - Yelena Piazza
- Pathology, University of Central Florida College of Medicine, Orlando, USA
- Pathology, UCF-Lake Nona Hospital, Orlando, USA
| | - Dhruv Patel
- Radiology, University of Central Florida College of Medicine, Orlando, USA
- Radiology, UCF-Lake Nona Hospital, Orlando, USA
| | - Vladimir Neychev
- Surgery, University of Central Florida College of Medicine, Orlando, USA
- Surgery, UCF-Lake Nona Hospital, Orlando, USA
| |
Collapse
|
4
|
Gao P, Yu Z, Wang Y, Xiu W. Nomogram for predicting adhesive small bowel obstruction following emergency gastrointestinal surgery. Langenbecks Arch Surg 2023; 408:388. [PMID: 37796313 DOI: 10.1007/s00423-023-03126-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/29/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Postoperative adhesions are frequent and significant complications that typically arise following abdominal surgery. Currently, the existing evidence for predicting the risk of adhesive small bowel obstruction (ASBO) after emergency gastrointestinal surgery (EGS) remains inadequate. A reliable perioperative model that quantifies the risk of ASBO after EGS serves as a practical tool for guiding individually tailored surveillance. METHODS A consecutive series of 1296 patients who underwent EGS for radiologically confirmed bowel/visceral inflammation or perforation between 2012 and 2022 at a tertiary academic medical center were included in this study to establish a best-fit nomogram. The nomogram was externally validated by assessing discrimination and calibration using an independent cohort from a separate medical center. RESULTS A total of 116 patients (8.9%) developed at least one episode of ASBO after EGS during a median follow-up duration of 26 months. The results of multivariable logistic analysis indicated that male sex (P = 0.043), preoperative albumin level (P = 0.002), history of pelvic radiotherapy (P = 0.038), laparotomy (P = 0.044), and intensive care unit stay ≥ 72 h (P = 0.047) were identified as independent risk factors for developing ASBO. By incorporating these predictors, the developed nomogram exhibited good accuracy in risk estimation, as evidenced by a guide-corrected C-index score of 0.852 (95% CI 0.667-0.920) in the external validation cohort. Decision curve analysis and clinical impact curve demonstrated a clinically effective predictive model. CONCLUSION By incorporating the nomogram as a supplemental tool in perioperative management, it becomes possible to accurately assess the individual's likelihood of developing ASBOs. This quantification enables surgeons to implement appropriate preventive measures, ultimately leading to improved outcomes.
Collapse
Affiliation(s)
- Puyue Gao
- Department of Gastroenterology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, Shandong, China
| | - Zongping Yu
- Department of Emergency General Surgery, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Yiqi Wang
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, Shandong, China
| | - Wenchao Xiu
- Department of Anorectal Center, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, Shandong, China.
| |
Collapse
|
5
|
Talaat A, Mcguirt A. Recurrent Solitary Fibrous Tumor in a 73-Year-Old Male Presenting With Small Bowel Obstruction: A Case Report. Cureus 2023; 15:e44297. [PMID: 37779748 PMCID: PMC10533948 DOI: 10.7759/cureus.44297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023] Open
Abstract
Solitary fibrous tumors (SFTs) are rare soft tissue tumors that can arise in the abdomen, pleura, and central nervous system, among other sites. Surgical resection is the mainstay of management, although recurrence rates remain substantial. This case describes a 73-year-old male treated surgically for both a recurrent SFT and small bowel obstruction (SBO) secondary to adhesions. The patient had undergone numerous intra-abdominal operations for malignant SFT since 1994, highlighting the importance of meticulous resection at the initial presentation of local disease.
Collapse
Affiliation(s)
- Adam Talaat
- Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Aron Mcguirt
- General Surgery, Bay Pines Veterans Affairs (VA) Health Care System, St. Petersburg, USA
| |
Collapse
|
6
|
Shokoohi H, Mayes KD, Peksa GD, Loesche MA, Becker BA, Boniface KS, Lahham S, Jang TB, Secko M, Gottlieb M. Multi-center analysis of point-of-care ultrasound for small bowel obstruction: A systematic review and individual patient-level meta-analysis. Am J Emerg Med 2023; 70:144-150. [PMID: 37290251 DOI: 10.1016/j.ajem.2023.05.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE The study aimed to assess the diagnostic accuracy of point-of-care ultrasound (POCUS) in identifying small bowel obstruction (SBO) and to investigate the impact of clinician experience level and body mass index (BMI) on POCUS performance for diagnosing SBO in the Emergency Department. METHODS We systematically searched PubMed and Cochrane databases from January 2011-2022. We performed a meta-analysis using individual patient-level data from prospective diagnostic accuracy studies from which we obtained data from the corresponding authors. Overall test characteristics and subgroup analysis across clinician experience levels and a range of BMI were calculated. The primary outcome was SBO as the final diagnosis during hospitalization. RESULTS We included Individual patient data from 433 patients from 5 prospective studies. Overall, 33% of patients had a final diagnosis of SBO. POCUS had 83.0% (95%CI 71.7%-90.4%) sensitivity and 93.0% (95%CI 55.3%-99.3%) specificity; LR+ was 11.9 (95%CI 1.2-114.9) and LR- was 0.2 (95%CI 0.1-0.3). Residents had exhibited a sensitivity of 73.0% (95%CI 56.6%-84.9%) and specificity of 88.2% (95%CI 58.8%-97.5%), whereas attendings had demonstrated a sensitivity of 87.7% (95%CI 71.1%-95.4%) and specificity of 91.4% (95%CI 57.4%-98.8%). Among those patients with BMI<30 kg/m2, POCUS showed a sensitivity of 88.6% (95%CI 79.5%-94.7%) and a specificity of 84.0% (95%CI 75.3%-90.6%), while patients with BMI ≥ 30 kg/m2 exhibited a sensitivity of 72.0% (95%CI 50.6%-87.9%) and specificity of 89.5% (95%CI 75.2%-97.1%). CONCLUSIONS POCUS correctly identified those patients with SBO with high sensitivity and specificity. Diagnostic accuracy was slightly reduced when performed by resident physicians and among patients with a BMI ≥ 30 kg/m2. REGISTRATION PROSPERO registration number: CRD42022303598.
Collapse
Affiliation(s)
- Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital- Harvard Medical School, 326 Cambridge Street, Suite 410, Boston, MA 02114, United States of America.
| | - Katherine Dickerson Mayes
- Harvard Affiliated Emergency Medicine Residency, Harvard Medical School, Boston, MA, United States of America
| | - Gary D Peksa
- Rush University Medical Center, Chicago, IL, United States of America
| | - Michael A Loesche
- Harvard Affiliated Emergency Medicine Residency, Harvard Medical School, Boston, MA, United States of America
| | - Brent A Becker
- Department of Emergency Medicine, Wellspan York Hospital, York, PA, United States of America
| | - Keith S Boniface
- Department of Emergency Medicine, George Washington University, Washington, DC, United States of America
| | - Shadi Lahham
- Department of Emergency Medicine, The University of California at Irvine, Orange, CA, United States of America
| | - Timothy B Jang
- Harbor-UCLA Medical Center, Torrance, CA, United States of America
| | - Michael Secko
- Renaissance School of Medicine, Stony Brook University Hospital, Stony Brook, NY, United States of America
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| |
Collapse
|
7
|
Sharma K, Arfan S, Thota SSP, Agbasi C, Khan L, Naqvi L, Tiesenga F. Small Bowel Obstruction Secondary to Laparoscopic Adjustable Gastric Band Connecting Tube Intertwinement Within the Mesentery: A Case Report. Cureus 2023; 15:e39945. [PMID: 37409211 PMCID: PMC10319446 DOI: 10.7759/cureus.39945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2023] [Indexed: 07/07/2023] Open
Abstract
Laparoscopic adjustable gastric banding (LAGB) is a technique used for the surgical management of morbid obesity. This report illustrates the case of a 46-year-old African American woman who presented with a rare case of small bowel obstruction (SBO) two years post-LAGB placement. SBO, in this case, was a result of LAGB connecting tube intertwinement within the mesentery, accompanied by adhesions. The patient was diagnosed clinically and radiologically by computed tomography (CT) scan, which showed high-grade SBO. Initially, an exploratory laparoscopy was conducted, which soon transformed into an exploratory laparotomy when the cause of obstruction was seen to be the intertwinement of the connecting tube of the gastric band with the mesentery. With the rise of bariatric procedures to combat the epidemic of obesity in American society, this rare complication secondary to one of the most widely performed procedures beckons the attention of bariatric surgeons, emergency personnel, and device manufacturers.
Collapse
Affiliation(s)
- Kapish Sharma
- General Surgery, Windsor University School of Medicine, Cayon, KNA
| | - Sara Arfan
- General Surgery, Windsor University School of Medicine, Cayon, KNA
| | | | - Chukwuma Agbasi
- General Surgery, Windsor University School of Medicine, Cayon, KNA
| | - Laiba Khan
- General Surgery, Avalon University School of Medicine, Willemstad, CUW
| | - Larab Naqvi
- General Surgery, Avalon University School of Medicine, Willemstad, CUW
| | | |
Collapse
|
8
|
Miladinovic D, Buxey K. Laparoscopic repair of an obturator hernia; a case report of a contemporary surgical technique. Int J Surg Case Rep 2023; 105:108066. [PMID: 36989633 PMCID: PMC10074567 DOI: 10.1016/j.ijscr.2023.108066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/17/2023] [Accepted: 03/19/2023] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Small bowel obstruction secondary to an obturator hernia is a rare presentation associated with high mortality. Prior to the development of laparoscopic surgery, a laparotomy would have been the management technique of choice for this rare presentation. CASE PRESENTATION An elderly female with a bowel obstruction secondary to an obturator hernia presented via the Emergency Department. A laparoscopic approach with the use of a haemostatic gauze plug was performed to repair the defect. CLINICAL DISCUSSION The evolution of surgical techniques, particularly with laparoscopy has resulted in overall benefits regarding patient outcomes. These benefits include lower post operative morbidity, shorter length of stay and decreased post operative pain. This report discusses a laparoscopic approach and the use of a gauze plug to manage an emergent small bowel obstruction secondary to an obturator hernia. CONCLUSION The use of a haemostatic gauze agent is an alternate and potentially advantageous approach for an obturator hernia repair in the emergency setting.
Collapse
Affiliation(s)
- Danjel Miladinovic
- Griffith Base Hospital, NSW, Australia; South-Eastern Sydney Network Prince of Wales Hospital, Prince of Wales Hospital, Avoca Street, Sydney, NSW, Australia; University of NSW, Sydney, Australia.
| | - Kenneth Buxey
- Griffith Base Hospital, NSW, Australia; Sandringham Hospital, Alfred Health, Australia
| |
Collapse
|
9
|
Chen B, Sheng WY, Ma BQ, Mei BS, Xiao T, Zhang JX. Progress in diagnosis and treatment of surgery-related adhesive small intestinal obstruction. Shijie Huaren Xiaohua Zazhi 2022; 30:1016-1023. [DOI: 10.11569/wcjd.v30.i23.1016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022] Open
Abstract
Adhesive small bowel obstruction is a relatively common surgical acute abdomen, which is caused by various factors that result in the contents of the small bowel failing to pass smoothly. The clinical symptoms include abdominal pain, distension, nausea and vomiting, and defecation disorder. The chance of adhesive small bowel obstruction to develop in patients with a history of abdominal surgery is around 2.4%. This paper discusses the most recent developments in the conservative and surgical management of adhesive small bowel obstruction based on clinical manifestation, laboratory analysis, and imaging examination.
Collapse
Affiliation(s)
- Biao Chen
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Wei-Yong Sheng
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Bing-Qing Ma
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Bo-Sheng Mei
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Tian Xiao
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Jin-Xiang Zhang
- Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| |
Collapse
|
10
|
Jang Y, Jung SM, Heo TG, Choi PW, Kim JI, Jung SW, Jun H, Shin YC, Um E. Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study. Ann Coloproctol 2022; 38:423-431. [PMID: 34875819 PMCID: PMC9816557 DOI: 10.3393/ac.2021.00710.0101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/23/2021] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Most of the causes of small bowel obstruction (SBO) in patients without a history of abdominal surgery are unclear at initial assessment. This study was conducted to identify the etiology and clinical characteristics of SBO in virgin abdomens and discuss the proper management. METHODS A retrospective review involving operative cases of SBO from a single institute, which had no history of abdominal surgery, was conducted between January 2010 and December 2020. Clinical information, including radiological, operative, and pathologic findings, was investigated to determine the etiology of SBO. RESULTS A total of 55 patients were included in this study, with a median age of 57 years and male sex (63.6%) constituting the majority. The most frequently reported symptoms were abdominal pain and nausea or vomiting. Neoplasm as an underlying cause accounted for 34.5% of the cases, of which 25.5% were malignant cases. In patients aged ≥60 years (n=23), small bowel neoplasms were the underlying cause in 12 (52.2%), of whom 9 (39.1%) were malignant cases. Adhesions and Crohn disease were more frequent in patients aged <60 years. Coherence between preoperative computed tomography scans and intraoperative findings was found in 63.6% of the cases. CONCLUSION There were various causes of surgical cases of SBO in virgin abdomens. In older patients, hidden malignancy should be considered as a possible cause of SBO in a virgin abdomen. Patients with symptoms of recurrent bowel obstruction who have no history of prior abdominal surgery require thorough medical history and close follow-up.
Collapse
Affiliation(s)
- Youngjin Jang
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Sung Min Jung
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea,Correspondence to: Sung Min Jung, M.D. Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea Tel: +82-31-911-7993, Fax: +82-31-911-7319 E-mail:
| | - Tae Gil Heo
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Pyong Wha Choi
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Jae Il Kim
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Sung-Won Jung
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Heungman Jun
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Yong Chan Shin
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Eunhae Um
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| |
Collapse
|
11
|
Naumann AA, Rodriguez VI, Shychuk A. Recurrent small bowel obstruction as a rare presentation of undiagnosed sarcoidosis. BMJ Case Rep 2022; 15:e252486. [PMID: 36423948 PMCID: PMC9693864 DOI: 10.1136/bcr-2022-252486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Sarcoidosis is an immune-mediated inflammatory disorder with unknown aetiology that is marked by non-caseating granulomas in affected organs. Pulmonary sarcoidosis is the most common manifestation, but gastrointestinal involvement, particularly in the small bowel, is exceedingly rare. While symptom-driven treatment guidelines that are steroid based are well established for pulmonary and few extrapulmonary manifestations (ie, cardiac, neurologic, renal), gastrointestinal sarcoidosis treatment is largely extrapolation with optimal management under investigation. Additionally, few works document small bowel obstruction related to small bowel sarcoidosis. We present a case of short-interval recurrent small bowel obstruction in a man in his sixties that revealed newly diagnosed sarcoidosis with suspected small bowel involvement who never underwent steroid therapy. The patient exhibited gastrointestinal symptoms, despite asymptomatic pulmonary disease and a course of prednisone may have reduced his risk of recurrence. We also review suggested gastrointestinal sarcoidosis treatment and surveillance guidelines with focus on the small bowel.
Collapse
Affiliation(s)
| | | | - Andrew Shychuk
- Medicine, University of Florida, Gainesville, Florida, USA
| |
Collapse
|
12
|
Victory Srinivasan N, Khan AI, Mashat GD, Hazique M, Khan KI, Ramesh P, Kanagalingam S, Zargham Ul Haq FNU, Penumetcha SS. Recurrence of Small Bowel Obstruction in Adults After Operative Management of Adhesive Small Bowel Obstruction: A Systematic Review. Cureus 2022; 14:e29141. [PMID: 36259040 PMCID: PMC9561403 DOI: 10.7759/cureus.29141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/13/2022] [Indexed: 11/22/2022] Open
Abstract
The objective of this article is to review the existing literature on postoperative recurrence of adhesive small bowel obstruction (ASBO). We performed a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching PubMed, Cochrane Library, and Google Scholar, to identify randomized controlled trials (RCTs) and observational studies investigating recurrence after operative management of ASBO. Our search yielded one RCT, one prospective study, and eight retrospective studies, totaling 36,178 patients. We used Cochrane risk-of-bias tool and the Newcastle-Ottawa scale to assess the risk of bias in the reviewed studies (RCTs and observational studies, respectively). Operative management was associated with a lower risk of recurrence than conservative management, while the difference in recurrence between laparoscopic and open surgery was inconclusive. Diffuse adhesions were associated with a greater risk of recurrence than single band adhesions. We conclude that the “common knowledge” that surgery increases the risk for recurrence of ASBO is outdated and should no longer be applied when determining treatment modalities for ASBO. While conservative treatment still has its place, we need not fear the possibility of shifting patients to operative management earlier.
Collapse
|
13
|
Goto DS, Wai CJ. Case report: caught by the pill cam…literally. J Surg Case Rep 2022; 2022:rjac353. [PMID: 35919693 PMCID: PMC9341302 DOI: 10.1093/jscr/rjac353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/13/2022] [Indexed: 11/29/2022] Open
Abstract
Small bowel obstructions are a common general surgery occurrence. In a patient with prior abdominal surgeries, the usual diagnosis is secondary to adhesions. The management is typically conservative, which usually avoids operative intervention. Computed tomography (CT) scans help diagnosticians take a snapshot inside the abdomen; however, CT scans are not perfect and intra-abdominal pathologies can be missed requiring surgery. We present a case of an atypical small bowel obstruction. The initial CT scan showed a transition point in the right lower quadrant, which was managed non-operatively. One week later, the patient then re-presented with hematochezia following an outpatient pill cam procedure. Imaging showed the presence of a new small bowel mass, which was not seen on imaging done 1 week ago or from 10 months prior. He was then taken for a diagnostic laparoscopy, in which a small bowel mass was found, pathology positive for recurrent renal cell carcinoma.
Collapse
Affiliation(s)
- Dylan S Goto
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii , Honolulu, HI , USA
| | - Christina J Wai
- Department of Surgery , Surgical Oncology, , Honolulu, HI , USA
- John A. Burns School of Medicine, University of Hawaii , Surgical Oncology, , Honolulu, HI , USA
| |
Collapse
|
14
|
Müller MH. Mechanische Obstruktion, paralytischer Ileus, postoperativer Ileus, Ileuskrankheit. SPRINGER REFERENCE MEDIZIN 2022:1-10. [DOI: 10.1007/978-3-662-61724-3_59-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 09/02/2023]
|
15
|
Azimi-Ghomi O, Kahane G. Ileal Tubulo-Villous Adenoma Causing Small Bowel Obstruction in a Virgin Abdomen. Cureus 2021; 13:e17421. [PMID: 34589331 PMCID: PMC8460552 DOI: 10.7759/cureus.17421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 12/29/2022] Open
Abstract
Small bowel obstructions (SBO) are a common surgical problem accounting for up half of all emergency laparotomies in the United States. SBO in the virgin abdomen (SBO-VA) presents surgeons with a unique predicament as historical teaching has mandated operative exploration in these situations due to their association with more sinister etiologies. More recent research has demonstrated that this may not be the case, with adhesive disease comprising the majority of SBO-VA. Small bowel neoplasms however comprise a considerable portion of SBO-VA. Small bowel tumors comprise around 0.5%-2% of all gastrointestinal tumors, with adenomas being the most common type of benign small bowel tumor. These lesions are most commonly encountered in the duodenum, typically involving the peri-ampullary region, Their incidence decreases with descent down the gastrointestinal tract, and are least commonly found in the ileum. Ileal adenomas have been increasingly described in the literature with the rise of advanced imaging and endoscopic capabilities. The vast majority of these lesions remain asymptomatic; however, they have been reported to undergo malignant transformation resulting in obstruction and intussusception. Small bowel obstruction due to ileal adenomas in the absence of malignancy is exceedingly rare, with only one previously reported case in the literature. We describe a case of an SBO-VA secondary to ileal stricture caused by a tubulo-villous adenoma. We then discuss the topics of SBO and SBO-VA, specifically regarding their etiology and historical and modern management, with a particular focus on the diagnosis and management of small bowel neoplasms, specifically small bowel adenomas.
Collapse
Affiliation(s)
| | - Gerardo Kahane
- General Surgery, Aventura Hospital and Medical Center, Aventura, USA
| |
Collapse
|
16
|
Amara Y, Leppaniemi A, Catena F, Ansaloni L, Sugrue M, Fraga GP, Coccolini F, Biffl WL, Peitzman AB, Kluger Y, Sartelli M, Moore EE, Di Saverio S, Darwish E, Endo C, van Goor H, Ten Broek RP. Diagnosis and management of small bowel obstruction in virgin abdomen: a WSES position paper. World J Emerg Surg 2021; 16:36. [PMID: 34217331 PMCID: PMC8254282 DOI: 10.1186/s13017-021-00379-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
Background Small bowel obstruction (SBO) is a common surgical emergency, causing high morbidity and healthcare costs. The majority of SBOs are caused by adhesions that result from previous surgeries. Bowel obstruction, however, also occurs in patients without previous operation or known pathology, a so called virgin abdomen. It is unknown if small bowel obstruction in the virgin abdomen (SBO-VA) can be managed according to the same principles as other cases of small bowel obstruction. The aim of this position paper is to evaluate the available evidence on etiology and management of small bowel obstruction in the virgin abdomen. Methods This is a narrative review with scoping aspects. Clinical topics covered in this review include epidemiology and etiology of SBO-VA, diagnosis and imaging, initial assessment, the role of surgical management in SBO-VA, and the role of non-operative management in SBO-VA. Results Our scoping search revealed seven original studies reporting original patient data related to SBO-VA. All the included studies are retrospective cohorts, with populations ranging between 44 and 103 patients with SBO-VA. Adhesions were found to be the cause of the obstruction in approximately half of the reported cases of SBO-VA. A relatively high number of cases of SBO-VA were managed surgically with studies reporting 39–83%. However, in cases where a trial of non-operative management was started, this was generally successful. Conclusion The data available suggest that etiology and treatment results for patients with SBO-VA are largely comparable to the results in patients with SBO after previous abdominal surgery. We therefore propose that patients with a virgin abdomen could be treated according to existing guidelines for SBO and adhesive small bowel obstruction.
Collapse
Affiliation(s)
- Yousef Amara
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of General Surgery, The Baruch Padeh Medical Centre, Poriya, Israel
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Fausto Catena
- Department of General Surgery, Parma University Hospital, Parma, Italy
| | - Luca Ansaloni
- General Emergency And Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM), Unicamp Campinas, São Paulo, Brazil
| | | | - Walter L Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, Hawaii, USA
| | - Andrew B Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus Haifa, Haifa, Israel
| | | | | | | | - Esfo Darwish
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Chikako Endo
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Richard P Ten Broek
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| |
Collapse
|
17
|
Dines JT, Harvey A. Chronic intentional chicken bone ingestion mimicking inflammatory bowel disease. BMJ Case Rep 2021; 14:14/6/e239022. [PMID: 34088681 DOI: 10.1136/bcr-2020-239022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Ingestion of food by-products, such as peach pits, chicken bones and fish bones, may lead to intestinal complications. The ingestion of the foreign body is often acute and non-intentional. Acute and life-threatening complications include intestinal perforation or obstruction. Sharp-pointed objects are associated with an estimated 35% rate of complications within the gastrointestinal tract prior to passage and require prompt removal. Endoscopic retrieval is often recommended if foreign objects have not transited beyond the proximal duodenum. We present a unique case of a previously healthy 23-year-old male suffering months of abdominal pain. While the initial presentation and imaging were suspicious for Crohn's disease, the endoscopic findings were unexpected. Numerous chicken bone fragments were clustered in the caecum and in the terminal ileum. The distal terminal ileum was edematous and ulcerated. Subsequent patient history revealed years of chronic and intentional foreign body consumption with recent onset of abdominal pain.
Collapse
Affiliation(s)
- Jacob T Dines
- Internal Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - Amie Harvey
- Internal Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| |
Collapse
|
18
|
Pan T, Galiullin D, Chen XL, Zhang WH, Yang K, Liu K, Zhao LY, Chen XZ, Hu JK. Incidence of adhesive small bowel obstruction after gastrectomy for gastric cancer and its risk factors: a long-term retrospective cohort study from a high-volume institution in China. Updates Surg 2021; 73:615-626. [PMID: 33550510 DOI: 10.1007/s13304-021-00983-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/20/2021] [Indexed: 02/08/2023]
Abstract
Adhesive small bowel obstruction (ASBO) has a significant impact on quality of life and medical costs. However, data about ASBO after gastrectomy remain sparse. From January 2009 to December 2017, 3025 patients who underwent gastrectomy for gastric cancer were retrospectively collected and analyzed. Clinicopathological materials were obtained retrospectively, and univariate and multivariate regression analyses were performed to determine risk factors for ASBO. A nomogram for the prediction of ASBO was generated using the results of multivariable analyses. Bootstraps with 1000 resamples were performed for internal validation. The performance of the model was assessed with its discrimination, calibration, and clinical usefulness. A total of 330 (10.9%) patients experienced at least one ASBO episode with a median follow-up of 57.0 (interquartile range 31.0-85.0) months. Logistic regression analysis showed that independent risk factors for ASBO were previous abdominal surgery (odds ratio, OR = 2.03), open gastrectomy (OR = 3.12), non-Billroth-1 reconstruction (Billroth-2, OR = 2.61; Roux-en-Y, OR = 1.99; esophagogastrostomy, OR = 2.79), D2/D2 + lymphadenectomy (OR = 2.64), combined organ resection (OR = 2.76), and postoperative intraabdominal complication (OR = 2.73). The nomogram showed good discrimination, with a C-index of 0.702 and good calibration. Decision curve analysis demonstrated that the nomogram was clinically useful. Several risk factors associated with ASBO after gastrectomy for gastric cancer were identified. Nomogram generated based on these factors could serve as a reliable tool to predict the probability of ASBO.
Collapse
Affiliation(s)
- Tao Pan
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 GuoXue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Danil Galiullin
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 GuoXue Xiang Street, Chengdu, 610041, Sichuan Province, China.,Department of Urology, Bashkir State Medical University, Ufa, Russian Federation
| | - Xiao-Long Chen
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 GuoXue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Wei-Han Zhang
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 GuoXue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Kun Yang
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 GuoXue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Kai Liu
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 GuoXue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Lin-Yong Zhao
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 GuoXue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Xin-Zu Chen
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 GuoXue Xiang Street, Chengdu, 610041, Sichuan Province, China
| | - Jian-Kun Hu
- Department of Gastrointestinal Surgery and Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center for Biotherapy, No 37 GuoXue Xiang Street, Chengdu, 610041, Sichuan Province, China.
| |
Collapse
|
19
|
Podda M, Khan M, Di Saverio S. Adhesive Small Bowel Obstruction and the six w's: Who, How, Why, When, What, and Where to diagnose and operate? Scand J Surg 2021; 110:159-169. [PMID: 33511902 DOI: 10.1177/1457496920982763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Approximately 75% of patients admitted with small bowel obstruction have intra-abdominal adhesions as their cause (adhesive small bowel obstruction). Up to 70% of adhesive small bowel obstruction cases, in the absence of strangulation and bowel ischemia, can be successfully treated with conservative management. However, emerging evidence shows that surgery performed early during the first episode of adhesive small bowel obstruction is highly effective. The objective of this narrative review is to summarize the current evidence on adhesive small bowel obstruction management strategies. MATERIALS AND METHODS A review of the literature published over the last 20 years was performed to assess Who, hoW, Why, When, What, and Where diagnose and operate on patients with adhesive small bowel obstruction. RESULTS Adequate patient selection through physical examination and computed tomography is the key factor of the entire management strategy, as failure to detect patients with strangulated adhesive small bowel obstruction and bowel ischemia is associated with significant morbidity and mortality. The indication for surgical exploration is usually defined as a failure to pass contrast into the ascending colon within 8-24 h. However, operative management with early adhesiolysis, defined as operative intervention on either the calendar day of admission or the calendar day after admission, has recently shown to be associated with an overall long-term survival benefit compared to conservative management. Regarding the surgical technique, laparoscopy should be used only in selected patients with an anticipated single obstructing band, and there should be a low threshold for conversion to an open procedure in cases of high risk of bowel injuries. CONCLUSION Although most adhesive small bowel obstruction patients without suspicion of bowel strangulation or gangrene are currently managed nonoperatively, the long-term outcomes following this approach need to be analyzed in a more exhaustive way, as surgery performed early during the first episode of adhesive small bowel obstruction has shown to be highly effective, with a lower rate of recurrence.
Collapse
Affiliation(s)
- M Podda
- Department of Emergency Surgery, Policlinico Universitario "Duilio Casula," Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - M Khan
- Department of General and Trauma Surgery, Brighton and Sussex University Hospital NHS Trust, Brighton, UK
| | - S Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Varese, Italy
| |
Collapse
|
20
|
Non-operative management of small bowel obstruction in virgin abdomen: a systematic review. Surg Today 2021; 51:1558-1567. [PMID: 33481087 DOI: 10.1007/s00595-020-02210-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 10/22/2022]
Abstract
The aim of this study was to systematically review the feasibility and safety of non-operative management of small bowel obstruction (SBO) in virgin abdomen. A systematic review was performed through December 2019. The primary outcome was the resolution of non-operative management of SBO in virgin abdomen. Secondary outcomes were the etiology of SBO and findings of exploratory laparotomy. Six studies were included in the analysis. Of the 442 patients, 2 with metastatic cancer received palliative care, and the management in 26 was not reported, so these patients were excluded. A total of 414 patients were ultimately analyzed, including 203 patients (49%) who were managed non-operatively and 211 (51%) who underwent surgical management. Of the 203 managed non-operatively, the condition of 194 (96%) was resolved without further intervention. The remaining 9 (5%) patients failed non-operative management and ultimately required surgery. Of the 211 patients who underwent surgical exploration, only 137 had their intraoperative findings reported. Adhesions (n = 67; 49%) were the main cause, followed by malignancy (n = 14; 10%) and others (n = 33; 24%). No cause was found in 23 patients (17%). In highly select cases of SBO with virgin abdomen, non-operative management can be attempted if patients are clinically stable and computed tomography does not demonstrate concerning features or obvious pathology. Further well-designed prospective studies will be required prior to the introduction of this concept in clinical practice, as current evidence remains heterogeneous.
Collapse
|
21
|
Figueiredo SMPD, Demola S. Successful use of water-soluble contrast in patients with small bowel obstruction and virgin abdomen: A case report. Int J Surg Case Rep 2021; 79:94-96. [PMID: 33453466 PMCID: PMC7811061 DOI: 10.1016/j.ijscr.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/02/2021] [Accepted: 01/02/2021] [Indexed: 11/25/2022] Open
Abstract
Trial of nonoperative management is standard of care for adhesive SBO. Prior surgery is the most common cause of adhesions. Management of SBO in patients without prior surgery is a challenge. This is a case of SBO in a virgin abdomen patient successfully managed nonoperatively.
Introduction and importance Nonoperative management of adhesive SBO is well established but remains a challenge in patients without prior abdominal surgery. We aim to report a case of successful nonoperative management with the use of enteral hypertonic water-soluble contrast administration in a patient with virgin abdomen. Case presentation A healthy 24-year old man with no previous surgery presented to the emergency room with one day of abdominal pain. A CT abdomen and pelvis was consistent with SBO without clear anatomic etiology. The patient refused surgical intervention, so we performed a trial of nonoperative management. On hospital day 2, a repeat CT A/P with enterally administered water-soluble contrast showed resolution of SBO. The patient has had no symptoms since hospital discharge on 6 months follow up. Clinical discussion Small bowel obstruction is most commonly secondary to adhesions from prior surgeries. Even in patients with virgin abdomen, adhesions are the cause of SBO in 53%–73%. Recent studies in patients with virgin abdomen showed that 92.1% that underwent nonoperative management did not have a recurrence of SBO with mean follow up of 4.5 years. The use of water-soluble contrast in patients with virgin abdomen was reported to have 92–97% success rate. A meta-analysis showed a pooled prevalence of 7.7% of malignant etiology of SBO in these patients, more common with previous SBO admission or history of malignancy. Conclusion Nonoperative management with the therapeutic use of hypertonic water-soluble contrast is a viable treatment option in select cases and avoids the morbidity of surgical exploration.
Collapse
Affiliation(s)
| | - Sara Demola
- Department of Surgery, University of Texas Medical Branch Hospital, 301 University Blvd, Galveston, TX 77555, United States
| |
Collapse
|
22
|
Reply to “Small-Bowel Dilatation Is the Most Consistent Feature of Transmural Intestinal Necrosis”. AJR Am J Roentgenol 2020; 215:W43. [DOI: 10.2214/ajr.20.23062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
23
|
Detz DJ, Podrat JL, Muniz Castro JC, Lee YK, Zheng F, Purnell S, Pei KY. Small bowel obstruction. Curr Probl Surg 2020; 58:100893. [PMID: 34130796 DOI: 10.1016/j.cpsurg.2020.100893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | - Yoon K Lee
- Houston Methodist Hospital, Houston, Texas
| | - Feibi Zheng
- Weill Cornell Medicine, Houston Methodist Hospital, Houston, Texas
| | | | | |
Collapse
|
24
|
Kasparian S, Burns E, Shehabeldin A, Awar M, Pingali SR. Recurrent small bowel obstruction caused by Burkitt lymphoma in an elderly man: a case report and review of the literature. J Med Case Rep 2020; 14:127. [PMID: 32782017 PMCID: PMC7422579 DOI: 10.1186/s13256-020-02449-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 07/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute small bowel obstruction is a common surgical emergency usually caused by abdominal adhesions, followed by intraluminal tumors from metastatic disease. Although lymphomas have been known to cause bowel obstruction, Burkitt lymphoma is seldom reported to induce an obstruction in the adult population. CASE PRESENTATION A 78-year-old Hispanic man with a history of abdominal interventions presented to our hospital with abdominal pain. Computed tomography revealed a partial small bowel obstruction attributed to local inflammation or adhesions. Medical management with bowel rest and nasogastric decompression resulted in resolution of symptoms and quick discharge. He returned 2 days later with worsening abdominal pain. Repeat imaging showed progression of the partial small bowel obstruction, but with an additional 1.6-cm nodular density abutting the anterior aspect of the gastric antrum and lobulated anterior gastric antral wall thickening. He was taken to the operating room, where several masses were found. Intraoperative frozen sections were consistent with lymphoma, and pathology later revealed Burkitt lymphoma. Disease was found on both sides of the diaphragm by positron emission tomography. After the initial resection and adjuvant chemotherapy, the patient is alive and well about 14 months after resection. CONCLUSIONS Small bowel obstruction is uncommonly due to Burkitt lymphoma in the geriatric population and is more frequently seen in the pediatric and young adult populations. Burkitt lymphoma is very aggressive with rapid cell turnover leading to significant morbidity. The rapid recurrence of an acute abdominal process should prompt an investigation for a more sinister cause such as malignancy.
Collapse
Affiliation(s)
- Saro Kasparian
- Department of Internal Medicine, Houston Methodist Hospital, Houston, TX, 77030, USA.
| | - Ethan Burns
- Department of Internal Medicine, Houston Methodist Hospital, Houston, TX, 77030, USA
| | - Ahmed Shehabeldin
- Department of Pathology, Houston Methodist Hospital, Houston, TX, 77030, USA
| | - Melina Awar
- Department of Internal Medicine, Houston Methodist Hospital, Houston, TX, 77030, USA
| | - Sai Ravi Pingali
- Department of Internal Medicine, Houston Methodist Hospital, Houston, TX, 77030, USA.,Division of Hematology and Oncology, Houston Methodist Hospital, Houston, TX, 77030, USA
| |
Collapse
|
25
|
Syed AS, Bonte A, Allaham LA, Goodman ER. Peach pit impaction presenting as gallstone ileus. BMJ Case Rep 2020; 13:13/7/e235363. [PMID: 32723781 DOI: 10.1136/bcr-2020-235363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Small bowel obstruction (SBO) secondary to fruit pit impaction is rare. The presence of an ovoid, stony body in the bowel lumen on radiologic imaging in a patient presenting with signs and symptoms of SBO is likely to raise concern for gallstone ileus. We report the case of a 56-year-old man who presented with a 1-day history of intermittent left-sided abdominal pain and nausea associated with a single episode of vomiting. CT scan of the abdomen and pelvis revealed a 3.3 cm impacted stony mass in the terminal ileum resulting in high-grade partial SBO. The mass had a hypodense centre encased within a hyperdense, ridged outer layer. The diagnostic impression was gallstone ileus. The object was removed via enterotomy and was found to be a peach pit.
Collapse
Affiliation(s)
- Abdus Samad Syed
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander Bonte
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laith Adnan Allaham
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elliot R Goodman
- Department of Surgery, Mount Sinai Health System, New York, New York, USA .,Department of Surgery, Beth Israel Medical Center, New York, New York, USA
| |
Collapse
|
26
|
Experimental Models of Partial Intestinal Obstruction in Young Mice: Establishment, and Evaluation. J Surg Res 2020; 252:206-215. [PMID: 32283334 DOI: 10.1016/j.jss.2020.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 02/10/2020] [Accepted: 03/09/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Partial small bowel obstruction (SBO) is a common, potentially hazardous, surgical entity caused by numerous factors in humans. A number of techniques have been reported as efficient to simulate partial SBO in murine models. However, there is little data concerning their long-term survival. Our study presents a novel technique and evaluates its long-term efficiency compared with other commonly used techniques. MATERIALS AND METHODS Sixty C57BL/6 mice aged 6 to 8 wk were randomly divided into five intervention groups: ligation, intestinal ring, partial ligation, microclips, and the novel triple suture technique. The ring groups were subdivided into narrow, medium, and wide ring and partial ligation groups were subdivided at 1/3, 1/2, and 2/3 of the lumen. Survival cutoff time was set at 4 wk. Animals were then euthanized and small bowel muscle layer thickness was histopathologically evaluated. RESULTS None of the animals of the ligation and the ring groups reached the cutoff survival time. The mortality rate of the partial ligation and the microclips groups at the 4-week period were 33.3% and 0%, respectively. However, elimination of the performed intervention was revealed at the time of euthanasia and no alterations of the muscle layer were revealed at histopathology. The "triple suture" group had a survival rate of 90% until euthanasia and the sutures were apparent in all cases. Macroscopic evaluation showed small to mild proximal lumen dilatation in 6 of 10 animals. Histopathological evaluation of the specimens confirmed the partial obstruction. CONCLUSIONS The "triple suture" technique is a new, robust, reliable, and inexpensive technique for experimental long-standing partial SBO, with very low mortality.
Collapse
|
27
|
Behman R, Nathens AB, Mason S, Byrne JP, Hong NL, Pechlivanoglou P, Karanicolas P. Association of Surgical Intervention for Adhesive Small-Bowel Obstruction With the Risk of Recurrence. JAMA Surg 2020; 154:413-420. [PMID: 30698610 DOI: 10.1001/jamasurg.2018.5248] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Adhesive small-bowel obstruction (aSBO) is a potentially chronic, recurring surgical illness. Although guidelines suggest trials of nonoperative management, the long-term association of this approach with recurrence is poorly understood. Objective To compare the incidence of recurrence of aSBO in patients undergoing operative management at their first admission compared with nonoperative management. Design, Setting, and Participants This longitudinal, propensity-matched, retrospective cohort study used health administrative data for the province of Ontario, Canada, for patients treated from April 1, 2005, through March 31, 2014. The study population included adults aged 18 to 80 years who were admitted for their first episode of aSBO. Patients with nonadhesive causes of SBO were excluded. A total of 27 904 patients were included and matched 1:1 by their propensity to undergo surgery. Factors used to calculate propensity included patient age, sex, comorbidity burden, socioeconomic status, and rurality of home residence. Data were analyzed from September 10, 2017, through October 4, 2018. Exposures Operative vs nonoperative management for aSBO. Main Outcomes and Measures The primary outcome was the rate of recurrence of aSBO among those with operative vs nonoperative management. Time-to-event analyses were used to estimate hazard ratios of recurrence while accounting for the competing risk of death. Results Of 27 904 patients admitted with their first episode of aSBO, 6186 (22.2%) underwent operative management. Mean (SD) patient age was 61.2 (13.6) years, and 51.1% (14 228 of 27 904) were female. Patients undergoing operative management were younger (mean [SD] age, 60.2 [14.3] vs 61.5 [13.4] years) with fewer comorbidities (low burden, 382 [6.2%] vs 912 [4.2%]). After matching, those with operative management had a lower risk of recurrence (13.0% vs 21.3%; hazard ratio, 0.62; 95% CI, 0.56-0.68; P < .001). The 5-year probability of experiencing another recurrence increased with each episode until surgical intervention, at which point the risk of subsequent recurrence decreased by approximately 50%. Conclusions and Relevance According to this study, operative management of the first episode of aSBO is associated with significantly reduced risk of recurrence. Guidelines advocating trials of nonoperative management for aSBO may assume that surgery increases the risk of recurrence putatively through the formation of additional adhesions. The long-term risk of recurrence of aSBO should be considered in the management of this patient population.
Collapse
Affiliation(s)
- Ramy Behman
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Avery B Nathens
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Mason
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - James P Byrne
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nicole Look Hong
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Petros Pechlivanoglou
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
28
|
Renko AE, Mirkin KA, Cooper AB. Peritoneal encapsulation: a rare cause of small bowel obstruction. BMJ Case Rep 2019; 12:12/4/e228594. [PMID: 30992285 DOI: 10.1136/bcr-2018-228594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Peritoneal encapsulation syndrome (PES) is a rare cause of small bowel obstruction (SBO) in patients with no prior history of abdominal surgery. First described by Cleland in 1868, PES is a congenital condition characterised by small bowel encasement in an accessory, but otherwise normal peritoneal membrane. 1 2 A result of abnormal rotation of the midgut during early development, the condition causes fibrous encapsulation of the intestines, thus preventing bowel distention.3 While preoperative diagnosis is difficult, several case reports have described clinical and imaging signs that can help clinicians with not only recognising the condition but also preparing appropriately for perioperative discovery of anatomical variants. 3 4.
Collapse
Affiliation(s)
- Abagayle E Renko
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Katelin A Mirkin
- Department of Surgery, Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Amanda B Cooper
- Department of Surgery, Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| |
Collapse
|
29
|
Strajina V, Kim BD, Zielinski MD. Small bowel obstruction in a virgin abdomen. Am J Surg 2019; 218:521-526. [PMID: 30885455 DOI: 10.1016/j.amjsurg.2019.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/29/2019] [Accepted: 02/03/2019] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Surgical exploration is still considered mandatory in the setting of small bowel obstruction (SBO) and a virgin abdomen by some large centers. The aim of this study is to determine the etiology of SBO in patients without prior abdominal operation. METHODS Retrospective review of the patients treated for SBO and virgin abdomen at the Mayo Clinic between 2006 and 2016 was performed. Follow up data, operative and pathologic findings were examined to determine the etiology of SBO. RESULTS Sixty patients met inclusion criteria; abdominal exploration was performed in 50 patients (83%) and 10 patients (17%) were managed non-operatively. Exploration was therapeutic in 29 (58%), negative in 20 (40%) and non-therapeutic in one patient (2%). Overall, 8 patients (13%) were diagnosed with a malignancy: right-sided colon cancer (n = 3), small bowel (SB) neuroendocrine tumor (n = 2), SB lymphoma (n = 2) and carcinomatosis peritonei (n = 1); Upon retrospective review, both SB neuroendocrine tumors and one SB lymphoma were visible on the initial imaging. Leukocytosis (p = .03) and no recent weight loss (p = .04) were associated with negative exploration. CONCLUSION Patients with SBO and virgin abdomen frequently have a benign etiology. Careful imaging review directed at subtle signs of an underlying malignancy is warranted. If non-operative management is chosen, close follow up is essential and it should include a careful personal and family history as well as updated colonoscopy.
Collapse
Affiliation(s)
| | - Brian D Kim
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
30
|
Vilz TO, Stoffels B, Strassburg C, Schild HH, Kalff JC. Ileus in Adults. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:508-518. [PMID: 28818187 DOI: 10.3238/arztebl.2017.0508] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 11/21/2016] [Accepted: 02/28/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Ileus is one of the more common suspected diagnoses in everyday clinical practice. The term can refer either to mechanical or to functional ileus. Any physician who takes care of patients can be confronted with these entities; thus, all should be familiar with them and competent in their management. METHODS Recommendations are summarized for the diagnostic evaluation and treatment of ileus of various causes on the basis of a selective literature review. RESULTS The manifestations of ileus and its degree of severity generally depend on the site of blockage. The rule until recently was that a patient with suspected mechanical ileus should be taken to surgery within 12 hours; today, however, ileus-particularly of the small bowel-can often be successfully treated conservatively. Likewise, functional ileus only rarely requires surgery: supportive measures, depending on the etiology, usually suffice. CONCLUSION Proper treatment depends on the timely determination of the pathogenesis (mechanical versus functional) and on close interdisciplinary collaboration. A special challenge is posed by patients with peritoneal involvement with cancer who present with symptoms of ileus, in whom a clear distinction between mechanical and functional causation cannot always be drawn.
Collapse
Affiliation(s)
- Tim O Vilz
- Department of General, Visceral-, Thoracic and Vascular Surgery, Bonn University Hospital; Department of Internal Medicine I, Bonn University Hospital; Department of Radiology, Bonn University Hospital
| | | | | | | | | |
Collapse
|
31
|
Evolving Management Strategies in Patients with Adhesive Small Bowel Obstruction: a Population-Based Analysis. J Gastrointest Surg 2018; 22:2133-2141. [PMID: 30051307 DOI: 10.1007/s11605-018-3881-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/10/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND In patients with adhesive small bowel obstruction (aSBO), the decision to operate as well as the timing and technique of surgery have significant impacts on clinical outcomes. Trends in the management of aSBO have not been described at the population level and guideline adherence is unknown. We sought to evaluate the secular trends in the management of aSBO in a large North American population. METHODS We used administrative data to identify patients admitted to hospital for their first episode of aSBO over 2005-2014. We evaluated temporal trends in admission for aSBO and in management practices using Cochran-Armitage tests. Multivariable logistic regressions were used to assess trends when controlling for potential confounders. RESULTS Patients (40,800) were admitted with their first episode of aSBO. The mean age was 68.5 years and 55% of patients were female. The population-based rate of admission for aSBO decreased over the study period, from 39.1 to 38.1 per 100,000 persons per year. There was a significant increase in the proportion of patients who underwent surgery for aSBO (19 to 23%, p < 0.0001). Among those who underwent surgery, there were significant increases in the proportions of patients who underwent laparoscopic procedures (4 to 14%, p < 0.0001) and who underwent surgery within 1 day of admission (51 to 60%, p < 0.0001). CONCLUSION Between 2005 and 2014, there was a decrease in the population-based rate of aSBO, which may reflect increased utilization of minimally invasive techniques. There were significant trends towards increased operative intervention, with surgery occurring earlier and increasingly using laparoscopic approach.
Collapse
|
32
|
Behman R, Nathens AB, Karanicolas PJ. Laparoscopic Surgery for Small Bowel Obstruction: Is It Safe? Adv Surg 2018; 52:15-27. [PMID: 30098610 DOI: 10.1016/j.yasu.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Ramy Behman
- Division of General Surgery, University of Toronto, 600 University Avenue, Toronto, ON M5G 1X5, Canada; Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room K3W-11, Toronto, Ontario M4N 3M5, Canada
| | - Avery B Nathens
- Division of General Surgery, University of Toronto, 600 University Avenue, Toronto, ON M5G 1X5, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D574, Toronto, Ontario M4N 3M5, Canada
| | - Paul J Karanicolas
- Division of General Surgery, University of Toronto, 600 University Avenue, Toronto, ON M5G 1X5, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room T2-16, Toronto, Ontario M4N 3M5, Canada.
| |
Collapse
|
33
|
Bower KL, Lollar DI, Williams SL, Adkins FC, Luyimbazi DT, Bower CE. Small Bowel Obstruction. Surg Clin North Am 2018; 98:945-971. [PMID: 30243455 DOI: 10.1016/j.suc.2018.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.
Collapse
Affiliation(s)
- Katie Love Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA.
| | - Daniel I Lollar
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Sharon L Williams
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Farrell C Adkins
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - David T Luyimbazi
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Curtis E Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| |
Collapse
|
34
|
Li PH, Tee YS, Fu CY, Liao CH, Wang SY, Hsu YP, Yeh CN, Wu EH. The Role of Noncontrast CT in the Evaluation of Surgical Abdomen Patients. Am Surg 2018. [DOI: 10.1177/000313481808400658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute surgical abdomen is commonly encountered in the ED and CT is widely used as an informative diagnostic tool to evaluate potential surgical indications. However, the adverse effects of contrast material used in CTscanning have been documented. We sought to delineate the role of noncontrast CT in the evaluation of patients with acute surgical abdomen. Between August 2015 and December 2015, patients with nontraumatic surgical abdomen who underwent preoperative CT were enrolled in the current study. The patients for whom the CT results permitted surgical decision-making were the focus of this study. The disease entities included acute appendicitis, acute cholecystitis, hollow organ perforation, mechanical bowel obstruction, intra-abdominal abscess that could not be drained percutaneously, and ischemic bowel disease. The results of contrast-enhanced and noncontrast CT were compared and analyzed. The surgical conditions identifiable by noncontrast CT were recorded. In total, 227 patients were enrolled in the study. In 90.7 per cent of patients overall, the findings indicating the need for surgical treatment were visualized on both the noncontrast and contrast-enhanced images (acute appendicitis: 89.3%, acute cholecystitis: 89.7%, hollow organ perforation: 97.4%, bowel obstruction: 100%, intra-abdominal abscess: 100%, and ischemic bowel disease: 55.6%). Noncontrast CT provides benefit for critical decision-making. Body mass index may affect the accuracy of noncontrast imaging in the evaluation of patients with surgical abdomen. In some specific situations, contrast enhancement remains necessary.
Collapse
Affiliation(s)
- Pei-Hua Li
- From the Departments of Trauma & Emergency Surgery and General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yu-San Tee
- From the Departments of Trauma & Emergency Surgery and General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Yuan Fu
- From the Departments of Trauma & Emergency Surgery and General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Liao
- From the Departments of Trauma & Emergency Surgery and General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Yu Wang
- From the Departments of Trauma & Emergency Surgery and General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Pao Hsu
- From the Departments of Trauma & Emergency Surgery and General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Nan Yeh
- From the Departments of Trauma & Emergency Surgery and General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - En-Haw Wu
- From the Departments of Trauma & Emergency Surgery and General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| |
Collapse
|
35
|
Use of Postmortem Computed Tomography to Detect Bowel Obstruction and its Relationship to the Cause of Death. Am J Forensic Med Pathol 2017; 39:30-37. [PMID: 29140803 DOI: 10.1097/paf.0000000000000365] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bowel distension frequently indicates bowel obstruction, which is a common diagnosis in clinical radiology. Typically, symptoms and complaints lead to radiological examinations and the detection of the etiology. Untreated intestinal obstructions can lead to a fatal outcome through cardiac failure due to septic shock. Certain of these cases undergo medicolegal investigations depending on the case history, the condition of the decedent, the location of the finding, or recent visits to medical professionals. Computed tomography (CT) is a recommended method in clinical radiology for the detection of bowel obstruction, which is indicated by bowel distension and further radiological signs (eg, the whirl sign, which indicates a volvulus). Postmortem CT (PMCT) has increased worldwide, but PMCT differs from clinical CT; thus, the question of whether PMCT is also reliable for the detection of bowel obstruction in decedents or is negatively affected by postmortem modifications should be discussed. This study consists of 10 cases displaying radiological signs of bowel obstruction. Apart from bowel distension, the most common radiological signs (whirl sign, coffee bean sign, bird beak sign, and u-shape sign) are described and depicted. All decedents underwent autopsy and had a postmortem interval of less than 72 hours. Based on these cases, we assess the reliability of PMCT for detecting bowel obstruction and determining its relationship to the cause of death.
Collapse
|
36
|
|
37
|
Laparoscopic Surgery for Adhesive Small Bowel Obstruction Is Associated With a Higher Risk of Bowel Injury. Ann Surg 2017; 266:489-498. [DOI: 10.1097/sla.0000000000002369] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
38
|
A Case of Midgut Volvulus Associated with a Jejunal Diverticulum. Case Rep Surg 2017; 2017:3173875. [PMID: 29410929 PMCID: PMC5749288 DOI: 10.1155/2017/3173875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 11/13/2017] [Indexed: 11/23/2022] Open
Abstract
Midgut volvulus in adults is a rare entity that may present with intermittent colicky abdominal pain mixed with completely asymptomatic episodes. This small bowel twist may result in complications of obstruction, ischemia, hemorrhage, or perforation. With a midgut volvulus, complications may be life-threatening, and emergent surgical intervention is the mainstay of treatment. This current case involves an 80-year-old woman with intermittent abdominal pain with increasing severity and decreasing interval of time to presentation. A CAT scan revealed mesenteric swirling with possible internal hernia. A diagnostic laparoscopy followed by laparotomy revealed a midgut volvulus, extensive adhesions involving the root of the mesentery, and a large jejunal diverticulum. The adhesions were lysed enabling untwisting of the bowel, allowing placement of the small bowel in the correct anatomic position and resection of the jejunal diverticulum. This is a rare case of midgut volvulus with intermittent abdominal pain, associated with jejunal diverticulum managed successfully. A midgut volvulus should be considered in the differential diagnosis of a patient who present with a small bowel obstruction secondary to an internal hernia, especially when a swirl sign is present on the CAT scan.
Collapse
|
39
|
Primarily Proximal Jejunal Stone Causing Enterolith Ileus in a Patient without Evidence of Cholecystoenteric Fistula or Jejunal Diverticulosis. Case Rep Surg 2016; 2016:8390724. [PMID: 27803836 PMCID: PMC5075608 DOI: 10.1155/2016/8390724] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 09/20/2016] [Indexed: 01/27/2023] Open
Abstract
Stone formation within the intestinal lumen is called enterolith. This stone can encroach into the lumen causing obstruction and surgical emergency. Jejunal obstruction by an enterolith is a very rare entity and often missed preoperatively. To our knowledge, most cases of jejunal obstruction, secondary to stone, were associated with biliary disease (cholecystoenteric fistula), bezoar, jejunal diverticulosis, or foreign body. Hereby we present a rare case report of small bowel obstruction in an elderly man who was diagnosed lately to have primary proximal jejunal obstruction by an enterolith without evidence of a cholecystoenteric fistula or jejunal diverticulosis. This patient underwent laparotomy, enterotomy with stone extraction, and subsequent primary repair of the bowel.
Collapse
|
40
|
Abstract
Gastro-duodenal obstruction encompasses a spectrum of benign and malignant disease. Historically, chronic peptic ulcer disease was the main cause of gastro-duodenal obstruction, whereas now malignant cause with gastric carcinomas for gastric obstruction and pancreatic tumors for duodenal obstruction predominate. This paper reviews the role of CT in diagnosing gastro-duodenal obstruction, its level, its cause by identifying intraluminal, parietal, or extrinsic process, and the presence of complication.
Collapse
|
41
|
Galia M, Agnello F, La Grutta L, Lo Re G, Cabibbo G, Grassedonio E, Gioia BG, Sparacia G, Lo Casto A, Lagalla R, Midiri M. Computed tomography of bowel obstruction: tricks of the trade. Expert Rev Gastroenterol Hepatol 2016; 9:1115-25. [PMID: 26092117 DOI: 10.1586/17474124.2015.1051030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Bowel obstruction (BO) is a frequent cause of hospitalization and surgical consultation for acute abdominal pain. It is usually suspected at physical examination, but clinical and laboratory data are often nonspecific. Thus, computed tomography plays a crucial role in a correct diagnosis of BO. Indeed, computed tomography can confirm a diagnosis of BO, and identify the location and cause of the obstruction. In this review, the computed tomography appearances of common and uncommon causes of BO and pseudo-obstruction are reviewed.
Collapse
Affiliation(s)
- Massimo Galia
- Section of Radiological Sciences, DIBIMED, University of Palermo, 90127 Palermo, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Catena F, Di Saverio S, Coccolini F, Ansaloni L, De Simone B, Sartelli M, Van Goor H. Adhesive small bowel adhesions obstruction: Evolutions in diagnosis, management and prevention. World J Gastrointest Surg 2016; 8:222-231. [PMID: 27022449 PMCID: PMC4807323 DOI: 10.4240/wjgs.v8.i3.222] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/04/2015] [Accepted: 01/07/2016] [Indexed: 02/06/2023] Open
Abstract
Intra-abdominal adhesions following abdominal surgery represent a major unsolved problem. They are the first cause of small bowel obstruction. Diagnosis is based on clinical evaluation, water-soluble contrast follow-through and computed tomography scan. For patients presenting no signs of strangulation, peritonitis or severe intestinal impairment there is good evidence to support non-operative management. Open surgery is the preferred method for the surgical treatment of adhesive small bowel obstruction, in case of suspected strangulation or after failed conservative management, but laparoscopy is gaining widespread acceptance especially in selected group of patients. "Good" surgical technique and anti-adhesive barriers are the main current concepts of adhesion prevention. We discuss current knowledge in modern diagnosis and evolving strategies for management and prevention that are leading to stratified care for patients.
Collapse
|
43
|
Pilla M, Byard RW. Omental adhesion, intestinal herniation, and unexpected death in the elderly. Forensic Sci Med Pathol 2016; 12:214-6. [PMID: 26902957 DOI: 10.1007/s12024-016-9754-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2016] [Indexed: 01/18/2023]
Affiliation(s)
- Mark Pilla
- Discipline of Anatomy and Pathology, School of Medicine, The University of Adelaide, Frome Rd, Adelaide, SA, 5005, Australia.,Forensic Science SA, 21 Divett Place, Adelaide, SA, Australia
| | - Roger W Byard
- Discipline of Anatomy and Pathology, School of Medicine, The University of Adelaide, Frome Rd, Adelaide, SA, 5005, Australia. .,Forensic Science SA, 21 Divett Place, Adelaide, SA, Australia.
| |
Collapse
|
44
|
Gangadhar K, Kielar A, Dighe MK, O’Malley R, Wang C, Gross JA, Itani M, Lalwani N. Multimodality approach for imaging of non-traumatic acute abdominal emergencies. Abdom Radiol (NY) 2016; 41:136-48. [PMID: 26830620 DOI: 10.1007/s00261-015-0586-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
"Acute abdomen" includes spectrum of medical and surgical conditions ranging from a less severe to life-threatening conditions in a patient presenting with severe abdominal pain that develops over a period of hours. Accurate and rapid diagnosis of these conditions helps in reducing related complications. Clinical assessment is often difficult due to availability of over-the-counter analgesics, leading to less specific physical findings. The key clinical decision is to determine whether surgical intervention is required. Laboratory and conventional radiographic findings are often non-specific. Thus, cross-sectional imaging plays a pivotal role for helping direct management of acute abdomen. Computed tomography is the primary imaging modality used for these cases due to fast image acquisition, although US is more specific for conditions such as acute cholecystitis. Magnetic resonance imaging or ultrasound is very helpful in patients who are particularly sensitive to radiation exposure, such as pregnant women and pediatric patients. In addition, MRI is an excellent problem-solving modality in certain conditions such as assessment for choledocholithiasis in patients with right upper quadrant pain. In this review, we discuss a multimodality approach for the usual causes of non-traumatic acute abdomen including acute appendicitis, diverticulitis, cholecystitis, and small bowel obstruction. A brief review of other relatively less frequent but important causes of acute abdomen, such as perforated viscus and bowel ischemia, is also included.
Collapse
|
45
|
|
46
|
Aref H, Nawawi A, Altaf A, Aljiffry M. Transient small bowel intussusception in an adult: case report with intraoperative video and literature review. BMC Surg 2015; 15:36. [PMID: 25881028 PMCID: PMC4416349 DOI: 10.1186/s12893-015-0020-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/17/2015] [Indexed: 11/25/2022] Open
Abstract
Background The term intussusception refers to invagination of a segment of the gastrointestinal tract into the lumen of an adjacent segment. This is a rare entity and it is more prevalent in children and less common in adults. The diagnosis of intussusception in adults is difficult as a result of the nonspecific signs and symptoms. As there are many common causes of acute abdomen, intussusception should be considered when more frequent etiologies have been ruled out. The laparoscopic approach offers both a diagnostic option and a therapeutic one for intussusception in adults. Case presentation We report a forty-one year old male patient, who presented to our Emergency Department complaining of peri-umbilical pain associated with nausea and vomiting for 1 day. Diagnosed with transient small bowel intussusception without any obvious underlying pathology. This report is the first to present an intra-operative video showing the small bowel intussuscepting and reducing spontaneously. Furthermore, the authors present a review about this rare condition, including previously reported similar cases in literature. Conclusion Transient intussusception is extremely rare and is a challenging condition. Imaging techniques, especially CT scan, are helpful in the diagnosis of intussusception. However, laparoscopy offers the advantage of distinguishing transient intussusception from persistent intussusception. Electronic supplementary material The online version of this article (doi:10.1186/s12893-015-0020-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Hager Aref
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abrar Nawawi
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abdulmalik Altaf
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Murad Aljiffry
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
| |
Collapse
|
47
|
Chen YC, Liu CH, Hsu HH, Yu CY, Wang HH, Fan HL, Chen RC, Chang WC. Imaging differentiation of phytobezoar and small-bowel faeces: CT characteristics with quantitative analysis in patients with small- bowel obstruction. Eur Radiol 2014; 25:922-31. [PMID: 25417124 DOI: 10.1007/s00330-014-3486-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 09/03/2014] [Accepted: 11/03/2014] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The objective is to use multidetector computed tomography (MDCT) to differentiate phytobezoar impaction and small-bowel faeces in patients with small-bowel obstruction (SBO). METHODS We retrospectively reviewed 91 consecutive SBO patients with surgically proven phytobezoars (n = 31) or adhesion with small-bowel faeces (n = 60). Two readers blinded to the diagnosis recorded the following MDCT features: degree of obstruction, transition point, mesenteric fatty stranding, intraperitoneal fluid, air-fluid level, pneumatosis intestinalis, and portal venous gas. MDCT measurements of the food debris length, attenuation, luminal diameter, and wall thickness of the obstructed bowel were also compared. RESULTS A higher grade of obstruction with an absence of mesenteric fatty stranding and intraperitoneal fluid was more commonly seen in the phytobezoar group than in the small-bowel faeces group (p < 0.01). The food debris length (phytobezoar, 5.7 ± 2.8 cm; small-bowel feces, 20.3 ± 7.9 cm, p < 0.01) and mean attenuation (phytobezoar, -59.6 ± 43.3 Hounsfield units (HU); small-bowel faeces, 8.5 ± 7.7 HU, p <0.01) were significantly different between the two groups. The ROC curve showed that food debris length <9.5 cm and mean attenuation value < -11.75 HU predicted phytobezoar impaction. CONCLUSIONS MDCT features with measurements of the food debris length and mean attenuation assist the differentiation of phytobezoar impaction and small-bowel faeces. KEY POINTS • MDCT examination helps to differentiate phytobezoar and small-bowel faeces. • A higher grade of obstruction is commonly associated with phytobezoar impaction. • Mesenteric fatty stranding and intraperitoneal fluid are frequently associated with small-bowel faeces. • Quantitative measurement of the obstructed bowel adds the diagnostic accuracy.
Collapse
Affiliation(s)
- Ya-Cheng Chen
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Chaudhery B, Newman PA, Kelly MD. Small bowel obstruction and perforation secondary to primary enterolithiasis in a patient with jejunal diverticulosis. BMJ Case Rep 2014; 2014:bcr-2014-203833. [PMID: 24626387 DOI: 10.1136/bcr-2014-203833] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We describe a rare case of small bowel obstruction and perforation secondary to a primary enterolith in an 84-year-old female patient with jejunal diverticulosis. She underwent an emergency laparotomy, small bowel resection and primary anastomosis. Multiple jejunal diverticula and a large stone were identified at the time of operation. Analysis of the stone demonstrated mainly faecal material consistent with a true primary enterolith. A literature search of Medline and PubMed revealed three cases similar to the one described. The pathogenesis and management of enterolithiasis in jejunal diverticular disease is considered.
Collapse
Affiliation(s)
- Baber Chaudhery
- Department of General Surgery, North Bristol NHS Trust, Bristol, UK
| | | | | |
Collapse
|
49
|
Water-soluble contrast agents in small bowel obstruction: a useful discriminator. AJR Am J Roentgenol 2013; 199:W783. [PMID: 23169754 DOI: 10.2214/ajr.12.8979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|