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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ambulatory thyroidectomy. Recommendations of the Association francophone de chirurgie endocrinienne (AFCE), with the Société française d'endocrinologie (SFE) and the Société française de médecine nucléaire (SFMN)

Before ambulatory thyroidectomy is proposed, the patient and his family and/or friends will need to be informed by the surgeon of the specificity of this procedure, the normal postoperative effects of a thyroidectomy, and potential complications. Also known as outpatient thyroid surgery, it can only be proposed by an experienced surgeon supported by an adequately trained medical and paramedical team. The healthcare establishment must be in possession of all the resources needed in ambulatory management, with continuity of care guaranteed 24h/24 7d/7 in the event of possible emergency rehospitalization. In all cases, contact the day after the operation between the healthcare facility and the patient is imperative. Ambulatory management can be proposed for lobo-isthmectomy or isthmectomy, possibly involving lymph node dissection. It is also possible for secondary totalization of thyroidectomy (following lobectomy). On the other hand, indications for single-stage total thyroidectomy must be limited and ensure proximity between the patient's home and a healthcare structure with a platform adapted to the pathology necessitating surgical intervention (non-plunging euthyroid goiter). A precise clinical pathway must be set out, including pre-, peri- and postoperative protocols having been formalized for surgery (hemostasis procedures) and for anesthesia (prevention of pain, of vomiting and of hypertension). We recommend at least 6hours of postoperative surveillance in outpatient care. When outpatient treatment is not possible or not recommended, hospitalization stay after thyroidectomy can be limited to 24hours, except in the event of postoperative complications, or a need for effectively dosed anticoagulant treatment.

Management of the injured bowel: preserving bowel continuity as a gold standard

Background

Management of bowel traumatic injuries is a challenge. Although anastomotic or suture leak remains a feared complication, preserving bowel continuity is increasingly the preferred strategy. The aim of this study was to evaluate the outcomes of such a strategy.

Methods

All included patients underwent surgery for bowel traumatic injuries at a high volume trauma center between 2007 and 2017. Postoperative course was analyzed for abdominal complications, morbidity and mortality.

Results

Among 133 patients, 78% had small bowel injuries and 47% had colon injuries. 87% of small bowel injuries and 81% of colon injuries were treated with primary repair or anastomosis, with no difference in treatment according to injury site (p = 0.381). Mortality was 8%. Severe overall morbidity was 32%, and abdominal complications occurred in 32% of patients. Risk factors for severe overall morbidity were stoma creation (p = 0.036), heavy vascular expansion (p = 0.005) and a long delay before surgery (p = 0.023). Fistula rate was 2.2%; all leaks occurred after repairing small bowel wounds.

Conclusion

Primary repair of bowel injuries should be the preferred option in trauma patient, regardless of the site—small bowel or colon—of the injury. Stoma creation is an important factor for postoperative morbidity, which should be weighed against the risk of an intestinal suture or anastomosis.

Association of Autofluorescence-Based Detection of the Parathyroid Glands During Total Thyroidectomy With Postoperative Hypocalcemia Risk: Results of the PARAFLUO Multicenter Randomized Clinical Trial

Importance

Because inadvertent damage of parathyroid glands can lead to postoperative hypocalcemia, their identification and preservation, which can be challenging, are pivotal during total thyroidectomy.

Objective

To determine if intraoperative imaging systems using near-infrared autofluorescence (NIRAF) light to identify parathyroid glands could improve parathyroid preservation and reduce postoperative hypocalcemia.

Design, Setting, and Participants

This randomized clinical trial was conducted from September 2016 to October 2018, with a 6-month follow-up at 3 referral hospitals in France. Adult patients who met eligibility criteria and underwent total thyroidectomy were randomized. The exclusion criteria were preexisting parathyroid diseases.

Interventions

Use of intraoperative NIRAF imaging system during total thyroidectomy.

Main Outcomes and Measures

The primary outcome was the rate of postoperative hypocalcemia (a corrected calcium <8.0 mg/dL [to convert to mmol/L, multiply by 0.25] at postoperative day 1 or 2). The main secondary outcomes were the rates of parathyroid gland autotransplantation and inadvertent parathyroid gland resection.

Results

A total of 245 of 529 eligible patients underwent randomization. Overall, 241 patients were analyzed for the primary outcome (mean [SD] age, 53.6 [13.6] years; 191 women [79.3%]): 121 who underwent NIRAF-assisted thyroidectomy and 120 who underwent conventional thyroidectomy (control group). The temporary postoperative hypocalcemia rate was 9.1% (11 of 121 patients) in the NIRAF group and 21.7% (26 of 120 patients) in the control group (between-group difference, 12.6% [95% CI, 5.0%-20.1%]; P = .007). There was no significant difference in permanent hypocalcemia rates (0% in the NIRAF group and 1.6% [2 of 120 patients] in the control group). Multivariate analyses accounting for center and surgeon heterogeneity and adjusting for confounders, found that use of NIRAF reduced the risk of hypocalcemia with an odds ratio of 0.35 (95% CI, 0.15-0.83; P = .02). Analysis of secondary outcomes showed that fewer patients experienced parathyroid autotransplantation in the NIRAF group than in the control group: respectively, 4 patients (3.3% [95% CI, 0.1%-6.6%) vs 16 patients (13.3% [95% CI, 7.3%-19.4%]; P = .009). The number of inadvertently resected parathyroid glands was significantly lower in the NIRAF group than in the control group: 3 patients (2.5% [95% CI, 0.0%-5.2%]) vs 14 patients (11.7% [95% CI, 5.9%-17.4%], respectively; P = .006).

Conclusions and Relevance

The use of NIRAF for the identification of the parathyroid glands may help improve the early postoperative hypocalcemia rate significantly and increase parathyroid preservation after total thyroidectomy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02892253.

A novel technique for diaphragm biopsies in human patients

BACKGROUND

The diaphragm is difficult to biopsy because of its anatomic location. We describe a new laparoscopic diaphragm biopsy technique.

MATERIAL AND METHODS

Fifty one patients with amyotrophic lateral sclerosis gave their consent to diaphragm biopsy in the context of an implanted phrenic nerve stimulation protocol (NCT01583088). The biopsy was taken from the costal diaphragm, after opening the parietal peritoneum with scissors, and by grasping the diaphragmatic muscle over the rib with toothed laparoscopy forceps.

RESULTS

The first four electrocoagulation biopsies were unsuitable for morphologic examination. The following 47 biopsies were therefore performed without electrocoagulation. The mean size of the biopsy fragments obtained after preparation was 3 ± 1 × 2 ± 1 × 1 ± 1 mm (maximum: 4 × 3 × 2 mm). A diaphragmatic injury occurred during the section in three cases requiring immediate suture without causing pneumothorax. A small pleural effusion was observed on the postoperative chest x-ray in one patient with a spontaneously favorable outcome. Numerous stains were able to be performed on the fragments obtained.

CONCLUSIONS

Diaphragm biopsy can be safely performed by laparoscopy and yields tissue suitable for our future histologic evaluation.

Ischaemic colitis: indications, extent, and results of standardized emergency surgery

BACKGROUND

Acute ischaemic colitis can occur postoperatively, mainly after aortic surgery, or spontaneously. Surgical treatment is debated. Study aim was to describe factors related to ischaemic colitis severity, determine if postoperative and spontaneous ischaemic colitis share similar outcomes, and evaluate results of standardized management.

METHODS

191 consecutive cases of ischaemic colitis observed from 1997 to 2012 were retrospectively analyzed: 119 (62%) after surgery and 72 (38%) spontaneous. Colon resection was performed for endoscopic type 2 colitis with multiple organ failure, and for every type 3. Types 1 and 2 without multiple organ failure were managed nonoperatively.

RESULTS

Seventeen patients (9%) were managed nonoperatively, without mortality. Mortality rate after resection was 48% (84/174), within 9 days (range, 0-152). Multivariate analysis found 2 independent factors associated with postoperative death: age≥75 years and multiple organ failure. The context in which ischaemic colitis occurred was not a risk factor for mortality. Mortality rates were 51% for final type 3 (66% with multiple organ failure, 17% without), 53% for final type 2 with multiple organ failure, and 0% for type 1 or type 2 without multiple organ failure.

CONCLUSION

An aggressive surgical approach in patients with ischaemic colitis seems justified in patients with multiple organ failure and findings of severe form of ischaemia at endoscopy.

Optimal nonsurgical management of peptic ulcer bleeding, including arterial embolization is associated with a mortality below 1%

BACKGROUND

Management of high-risk peptic ulcer bleeding (PUB) consists in a high-dose infusion of proton pump inhibitors (PPIs) with double endoscopic treatment. If bleeding recurs, a second endoscopic treatment is required. Surgical management should be performed in case of endoscopic treatment failure, or if a second rebleeding occurs. Arterial embolization of PUB has been shown efficient and safe in small retrospective series, but optimal medical treatment was not used.

OBJECTIVE

Prospective assessment of the feasibility and the efficacy of arterial embolization of endoscopically unmanageable PUB, after optimal medical treatment.

PATIENTS

All consecutive patients referred to our intensive care unit (ICU) for high-risk PUB received high-dose PPIs and underwent double endoscopic treatment when possible. Arterial embolization was proposed in primary failure to endoscopic treatment, in case of failure of the second endoscopic treatment, or if a second recurrence occurred.

RESULTS

One hundred and twenty-eight patients with PUB were enrolled between January 2008 and December 2009. Arterial embolization, performed in 11 patients, was efficient in nine patients. Surgery was performed in two patients (one after inefficient embolization, and one with embolization-related complication). One patient died during hospitalization.

CONCLUSION

Arterial embolization seems to be efficient for endoscopically unmanageable PUB. In our series, one patient developed severe complication related to the procedure and died. If arterial embolization could be proposed before surgery in case of refractory PUB, large prospective studies are needed.

Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Pancreatic fistula (PF) after pancreatoduodenectomy (PD) remains a challenging problem. The only commonly accepted risk factor is the soft consistency of the pancreatic remnant.

METHODS

In all, 100 consecutive patients underwent PD. All data, including commonly accepted risk factors for PF and PF defined according to the International Study Group of Pancreatic Fistula, were collected prospectively. On the pancreatic margin, a score of fibrosis and a score of fatty infiltration were assessed by a pathologist blinded to the postoperative course.

RESULTS

PF occurred in 31% of patients. In univariate analysis, male sex, age greater than 58 years, body mass index (BMI) > or =25 kg/m(2), pre-operative high blood pressure, operation for nonintraductal papillary and mucinous neoplasm (IPMN) disease and for ampullary carcinoma, operative time, blood loss, soft consistency of the pancreatic remnant, absence of pancreatic fibrosis, and presence of fatty infiltration of the pancreas were associated with a greater risk of PF. In a multivariate analysis, only BMI > or =25 kg/m(2), absence of pancreatic fibrosis, and presence of fatty pancreas were significant predictors of PF. A score based on the number of risk factors present divided the patient population into 4 subgroups carrying a risk of PF that ranged from 7% (no risk factor) to 78% (3 risk factors) and from 0% to 81%, taking into account only symptomatic PF (grade B and C).

CONCLUSION

The presence of an increased BMI, the presence of fatty pancreas, and the absence of pancreatic fibrosis as risk factors of PF allows a more precise and objective prediction of PF than the consistency of pancreatic remnant alone. A predictive score based on these 3 factors could help to tailor preventive measures.