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Alsaiari A. Metastatic Urothelial Cancer Presenting as Small Bowel Obstruction: A Case Report. Cureus 2024; 16:e61228. [PMID: 38939301 PMCID: PMC11210193 DOI: 10.7759/cureus.61228] [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: 05/28/2024] [Indexed: 06/29/2024] Open
Abstract
Neoplasms are among the common causes of small bowel obstruction (SBO). Metastatic disease is the most common cause of neoplastic SBO and is most commonly the result of colon, ovarian, pancreatic, and gastric neoplasms. Metastatic SBO secondary to metastatic urothelial carcinoma is exceedingly rare, with only a few cases described in the literature. It is important for physicians to be aware of urothelial carcinoma as a potential etiology of SBO.
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Affiliation(s)
- Ahmed Alsaiari
- Department of Internal Medicine, University of Jeddah, Jeddah, SAU
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, USA
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2
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VON-Diemen V, Volkweis BS, Martins EF, Silva LLDM, Cavazzola LT. THE WATER-SOLUBLE CONTRAST FOR ADHESIVE SMALL BOWEL OBSTRUCTION: ARE THERE ADVANTAGES? ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1777. [PMID: 38088723 PMCID: PMC10712923 DOI: 10.1590/0102-672020230059e1777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/21/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Adhesive small bowel obstruction is one of the most common causes of surgical emergencies, representing about 15% of hospital admissions. Defining the need and timing of surgical intervention still remains a challenge. AIMS To report the experience of using meglumine-based water-soluble contrast in a tertiary hospital in southern Brazil, comparing with the world literature. METHODS Patients suspected of having adhesive small bowel obstruction, according to their clinical conditions, underwent an established protocol, consisting of the administration of water-soluble contrast, followed by plain abdominal radiograph within 12 hours and by a new clinical evaluation. The protocol was initiated after starting conservative management, including fasting and placement of a nasogastric tube, as well as intravenous fluid reposition. RESULTS A total of 126 patients were submitted to the protocol. The water-soluble contrast test sensitivity and specificity after the first radiograph were 94.6 and 91.0%, respectively; after the second radiograph, these values were 92.3 and 100%. The general test values for sensitivity and specificity were 91.9 and 100%, respectively. CONCLUSIONS The measure parameters evaluated in this study were similar to those found in the literature, contributing to endorse the importance of this test in the evaluation of patients with adhesive small bowel obstruction. The particular relevance of this study was the similar results that were found using a different type of meglumine-based contrast, which is available in Brazil.
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Affiliation(s)
- Vinicius VON-Diemen
- Universidade Federal do Rio Grande do Sul, Porto Alegre University Hospital, General Surgery Service - Porto Alegre (RS), Brazil
| | - Bernardo Silveira Volkweis
- Universidade Federal do Rio Grande do Sul, Porto Alegre University Hospital, General Surgery Service - Porto Alegre (RS), Brazil
| | - Eduardo Ferreira Martins
- Universidade Federal do Rio Grande do Sul, Porto Alegre University Hospital, General Surgery Service - Porto Alegre (RS), Brazil
| | - Lara Luz de Miranda Silva
- Universidade Federal do Rio Grande do Sul, Porto Alegre University Hospital, General Surgery Service - Porto Alegre (RS), Brazil
| | - Leandro Totti Cavazzola
- Universidade Federal do Rio Grande do Sul, Porto Alegre University Hospital, General Surgery Service - Porto Alegre (RS), Brazil
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3
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Mararenko A, Douedi S, Alshami A, Odak M, Patel SV. Rare Case of Small Bowel Obstruction Secondary to Cryptosporidium in a Young Patient With Uncontrolled AIDS. Cureus 2021; 13:e16040. [PMID: 34336522 PMCID: PMC8321418 DOI: 10.7759/cureus.16040] [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] [Accepted: 06/29/2021] [Indexed: 11/05/2022] Open
Abstract
Small bowel obstruction is a common cause of abdominal pain and accounts for approximately 20% of surgical admissions related to abdominal pain. In the United States alone, there are over 300,000 admissions annually for small bowel obstruction and account for every 15 out of 100 admissions for abdominal pain. If treated appropriately with medical management, over 80% of cases resolve without life-threatening, long-term complications or the need for surgical intervention. The three most common causes including adhesions, tumors, and hernias account for the majority of cases. Less frequently reported causes include infections. We present the case of a 26-year-old male with a history of AIDS who was found to have a small bowel obstruction in the setting of active Cryptosporidium infection. Cryptosporidium is an opportunistic infection that more commonly affects immunocompromised hosts, especially those noncompliant with antiretroviral therapy. Our patient had an uncomplicated hospital course and made a full recovery due to early diagnosis and immediate intervention. We hope to make the medical community more aware of this rare and potentially life-threatening association given the rarity of such a presentation. Early diagnosis and intervention are critical to preventing morbidity and mortality.
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Affiliation(s)
- Anton Mararenko
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Steven Douedi
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Abbas Alshami
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Mihir Odak
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Swapnil V Patel
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
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4
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Gu L, Zhu F, Xie T, Feng D, Gong J, Li N. Use of the Water-Soluble Contrast Medium Gastrografin in Treatment of Adhesive Small Bowel Obstruction in Patients with and Without Chronic Radiation Enteropathy: A Single-Center Retrospective Study. Med Sci Monit 2021; 27:e930046. [PMID: 33771966 PMCID: PMC8011282 DOI: 10.12659/msm.930046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background This retrospective cohort study from a single center aimed to compare patient outcomes following the use of the water-soluble contrast medium Gastrografin in the treatment of adhesive small bowel obstruction (ASBO) in patients with and without a history of chronic radiation enteropathy (CRE). Material/Methods Fifty-nine patients with CRE-induced small bowel obstruction (SBO) and 53 patients with ASBO at Jinling Hospital between April 2014 and February 2018 were enrolled. The patients were given 100 ml Gastrografin through a naso-jejunal tube, and erect abdominal X-rays were taken. Risk factors were found to be correlated with successful non-operative management (SNM) through statistical analyses. Results The success rate of conservative treatment was higher in the Gastrografin group than in the control group (P<0.05). The Gastrografin challenge test is predictive of need for surgery in CRE-induced SBO and ASBO (AUC=0.860 and 0.749, respectively). The predictors associated with SNM in the CRE-induced SBO group were the total dose of radiotherapy, the Gastrografin challenge test, and previous operations for SBO. In the ASBO group, the predictors were the Gastrografin challenge test and previous operations for SBO. The operation rate of SBO patients with Gastrografin treatment was significantly lower than that in the control group (P<0.05). Conclusions The findings from this study showed that the use of Gastrografin effectively resolved ASBO in patients with and without a history of CRE, but a long-term requirement for surgery could not be avoided. The Gastrografin challenge may be a useful test to predict surgical outcomes.
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Affiliation(s)
- Lili Gu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China (mainland)
| | - Feng Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China (mainland)
| | - Tingbin Xie
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China (mainland)
| | - Dengyu Feng
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China (mainland)
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China (mainland)
| | - Ning Li
- Department of Colorectal Disease, Intestinal Microenvironment Treatment Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
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5
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Huang X, Xue J, Gao M, Qin Q, Ma T, Li X, Wang H. Medical Management of Inoperable Malignant Bowel Obstruction. Ann Pharmacother 2020; 55:1134-1145. [PMID: 33345552 DOI: 10.1177/1060028020979773] [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: 12/24/2022] Open
Abstract
OBJECTIVE To review medical management of inoperable malignant bowel obstruction. DATA SOURCES A literature review using PubMed and MEDLINE databases searching malignant bowel obstruction, etiology, types, pathophysiology, medical, antisecretory, anti-inflammatory, antiemetic drugs, analgesics, promotion of emptying, prevention of infection, anticholinergics, somatostatin analogs, gastric antisecretory drugs, prokinetic agents, glucocorticoid, opioid analgesics, antibiotics, enema, and adverse effects. STUDY SELECTION AND DATA EXTRACTION Randomized or observational studies, cohorts, case reports, or reviews written in English between 1983 and November 2020 were evaluated. DATA SYNTHESIS Malignant bowel obstruction (MBO) commonly occurs in patients with advanced or recurrent malignancies and severely affects the quality of life and survival of patients. Its management remains complex and variable. Medical management is the cornerstone of MBO treatment, with the goal of reducing distressing symptoms and optimizing quality of life. Until now, there has been neither a standard clinical approach nor registered medications to treat patients with inoperable MBO. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review provides information on the etiology, type and pathophysiology, and medical treatment of MBO and related adverse reactions of the drugs commonly used, which can greatly assist clinicians in making clinical decisions when treating MBO. CONCLUSIONS Published research shows that medical management of MBO mainly consists of antisecretory, anti-inflammatory strategies, controlling vomiting and pain, promoting emptying, preventing infection, and combination therapy. Being knowledgeable about the most current treatment options, the related adverse effects, and the evidence supporting different practices is critical for clinicians to provide individualized medical therapy for MBO patients.
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Affiliation(s)
- Xiaoyan Huang
- Sun Yat-sen University Sixth Affiliated Hospital, Guangzhou, Guangdong, China
| | - Jing Xue
- Sun Yat-sen University Sixth Affiliated Hospital, Guangzhou, Guangdong, China
| | - Min Gao
- Sun Yat-sen University Sixth Affiliated Hospital, Guangzhou, Guangdong, China
| | - Qiyuan Qin
- Sun Yat-sen University Sixth Affiliated Hospital, Guangzhou, Guangdong, China
| | - Tenghui Ma
- Sun Yat-sen University Sixth Affiliated Hospital, Guangzhou, Guangdong, China
| | - Xiaoyan Li
- Sun Yat-sen University Sixth Affiliated Hospital, Guangzhou, Guangdong, China
| | - Hui Wang
- Sun Yat-sen University Sixth Affiliated Hospital, Guangzhou, Guangdong, China
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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
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7
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Lyu H, Manca C, McGrath C, Beloff J, Plaks N, Postilnik A, Borchers A, Diaz N, McGovern S, Havens J, Kachalia A, Landman A. Development of a Web-Based Nonoperative Small Bowel Obstruction Treatment Pathway App. Appl Clin Inform 2020; 11:535-543. [PMID: 32814352 DOI: 10.1055/s-0040-1715478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE An electronic pathway for the management of adhesive small bowel obstruction (SBO) was built and implemented on top of the electronic health record. The aims of this study are to describe the development of the electronic pathway and to report early outcomes. METHODS The electronic SBO pathway was designed and implemented at a single institution. All patients admitted to a surgical service with a diagnosis of adhesive SBO were enrolled. Outcomes were compared across three time periods: (1) patients not placed on either pathway from September 2013 through December 2014, (2) patients enrolled in the paper pathway from January 2017 through January 2018, and (3) patients enrolled in the electronic pathway from March through October 2018. The electronic SBO pathway pulls real-time data from the electronic health record to prepopulate the evidence-based algorithm. Outcomes measured included length of stay (LOS), time to surgery, readmission, surgery, and need for bowel resection. Comparative analyses were completed with Pearson's chi-squared, analysis of variance, and Kruskal-Wallis tests. RESULTS There were 46 patients enrolled in the electronic pathway compared with 93 patients on the paper pathway, and 101 nonpathway patients. Median LOS was lower in both pathway cohorts compared with those not on either pathway (3 days [range 1-11] vs. 3 days [range 1-27] vs. 4 days [range 1-13], p = 0.04). Rates of readmission, surgery, time to surgery, and bowel resection were not significantly different across the three groups. CONCLUSION It is feasible to implement and utilize an electronic, evidence-based clinical pathway for adhesive SBOs. Use of the electronic and paper pathways was associated with decreased hospital LOS for patients with adhesive SBOs.
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Affiliation(s)
- Heather Lyu
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Caitlin Manca
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Casey McGrath
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Jennifer Beloff
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Nina Plaks
- Partners HealthCare, Somerville, Massachusetts, United States
| | | | - Amanda Borchers
- Partners HealthCare, Somerville, Massachusetts, United States
| | - Nicasio Diaz
- Partners HealthCare, Somerville, Massachusetts, United States
| | - Sean McGovern
- Partners HealthCare, Somerville, Massachusetts, United States
| | - Joaquim Havens
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Allen Kachalia
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, United States
| | - Adam Landman
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Partners HealthCare, Somerville, Massachusetts, United States.,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Hospital, Baltimore, Maryland, United States
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8
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Abstract
Small bowel obstruction (SBO) remains a common reason for emergency/unplanned admissions, and remains a significant burden to SBO patients and the healthcare system alike. The management of SBO has undergone a significant paradigm shift over the years, shifting far from the tenet to "never let the sun rise on a bowel obstruction." Not only has the timing to surgery changed, but there is also an increased utilization of diagnostic tools to aid clinical decision-making. Furthermore, the surgical management is beginning to favor a less invasive approach. This review will serve to provide an up-to-date review of the evaluation and management of SBO, based on the most recent available evidence and our experience with the methods described.
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9
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Fung BSC, Behman R, Nguyen MA, Nathens AB, Look Hong NJ, Pechlivanoglou P, Karanicolas PJ. Longer Trials of Non-operative Management for Adhesive Small Bowel Obstruction Are Associated with Increased Complications. J Gastrointest Surg 2020; 24:890-898. [PMID: 31062274 DOI: 10.1007/s11605-019-04156-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 02/05/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Current guidelines for the management of adhesive small bowel obstruction suggest a limited trial of non-operative management, often of 3-5 days. A longer delay to operation may worsen post-operative outcomes in patients who ultimately require operation. Our objective was to evaluate the impact of time to operation on post-operative outcomes in patients who undergo operation following a trial of non-operative management for adhesive small bowel obstruction. METHODS We used health administrative data to identify patients with adhesive small bowel obstruction who underwent operative management following a trial of non-operative management from 2005 to 2014 in the province of Ontario, Canada. We used multivariable logistic regression to examine the relationship between the time from admission to operation with rates of 30-day mortality, serious complication, and bowel resection. RESULTS Three thousand five hundred sixty-three patients underwent operation after a trial of non-operative management for adhesive small bowel obstruction. Older patients, patients with a high comorbidity burden, and patients with a lower socioeconomic status were more likely to experience a longer pre-operative period. After adjusting for covariates, each additional day from admission to operation increased odds of serious complication (OR = 1.07, 95% CI = 1.03-1.11) and bowel resection (OR = 1.06, 95% CI = 1.03-1.98). Longer times to operation were not associated with greater adjusted odds of 30-day mortality. CONCLUSION Each additional day from admission to operation is associated with greater odds of adverse outcomes. Clinical practice guidelines should emphasize strategies that identify patients who will ultimately require operation.
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Affiliation(s)
- Benjamin S C Fung
- Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, T2-016, Toronto, ON, M4N3M5, Canada
| | - Ramy Behman
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - May-Anh Nguyen
- Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, T2-016, Toronto, ON, M4N3M5, Canada
| | - Avery B Nathens
- Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, T2-016, Toronto, ON, M4N3M5, Canada
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Nicole J Look Hong
- Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, T2-016, Toronto, ON, M4N3M5, Canada
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Petros Pechlivanoglou
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, T2-016, Toronto, ON, M4N3M5, Canada.
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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10
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Robertson R, Wu L. Adhesive small bowel obstruction in pregnancy and the use of oral contrast media: a case report. J Surg Case Rep 2020; 2020:rjaa018. [PMID: 32161637 PMCID: PMC7059893 DOI: 10.1093/jscr/rjaa018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 01/25/2020] [Indexed: 01/18/2023] Open
Abstract
Bowel obstruction in pregnancy is a high risk situation for both the mother and baby. We present a case of a 30-week-pregnant woman who presented with abdominal pain and vomiting and was diagnosed with adhesive small bowel obstruction (SBO). Oral contrast media was successfully used as a treatment. The patient was discharged home and 10 weeks later delivered a healthy baby girl. We were unable to find any cases in the literature describing oral contrast media to treat adhesive SBO in pregnancy. From our experience and research, we consider oral contrast media as a method of treating adhesive SBO in pregnancy under the proviso that there are no signs that indicate urgent surgical intervention.
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Affiliation(s)
| | - Linus Wu
- General Surgery, Waikato Hospital, Hamilton, New Zealand
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11
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Tong JWV, Lingam P, Shelat VG. Adhesive small bowel obstruction - an update. Acute Med Surg 2020; 7:e587. [PMID: 33173587 PMCID: PMC7642618 DOI: 10.1002/ams2.587] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/05/2020] [Accepted: 09/18/2020] [Indexed: 12/13/2022] Open
Abstract
Small bowel obstruction (SBO) accounts for 12-16% of emergency surgical admissions and 20% of emergency surgical procedures. Even with the advent of laparoscopic surgery, intra-abdominal adhesions remain a significant cause of SBO, accounting for 65% of cases. History and physical examination are essential to identify signs of bowel ischemia as this indicates a need for urgent surgical exploration. Another critical aspect of evaluation includes establishing the underlying cause for obstruction and distinguishing between adhesive and non-adhesive etiologies as adhesive SBO (ASBO) can be managed non-operatively in 70-90% of patients. A patient with a history of abdominopelvic surgery along with one or more cardinal features of obstruction should be suspected to have ASBO until proven otherwise. Triad of severe pain, pain out of proportion to the clinical findings, and presence of an abdominal scar suggest possible closed-loop obstruction. Computed tomography has higher sensitivity and specificity compared to plain films and is recommended by the Bologna guidelines. Correcting fluid and electrolyte imbalance is an initial crucial step to mitigate severe hypovolemia. Patients should proceed with surgery if symptoms of bowel compromise are present, or if symptoms do not resolve or have worsened. Surgery is indicated in patients with ischemia, strangulation, perforation, peritonitis, or failure of non-operative treatment. With advances in minimal access technology and increasing experience, laparoscopic adhesiolysis is recommended. Mechanical adhesion barriers are an effective measure to prevent adhesion formation.
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Affiliation(s)
- Jia Wei Valerie Tong
- Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
| | - Pravin Lingam
- Department of General SurgeryTan Tock Seng HospitalSingaporeSingapore
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12
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Paily A, Kotecha J, Sreedharan L, Kumar B. Resolution of adhesive small bowel obstruction with a protocol based on Gastrografin administration. J Med Life 2019; 12:10-14. [PMID: 31123519 PMCID: PMC6527405 DOI: 10.25122/jml-2018-0082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The use of Gastrografin may have a therapeutic effect on resolving adhesive small bowel obstruction. Adhesive Small Bowel obstruction (ASBO) accounts for the majority of patients with small bowel obstruction. Most patients are managed conservatively; frequent admissions create a considerable burden. We sought to examine the adherence to the Bologna guidelines for the management of ASBO in a high volume tertiary center and whether or not Gastrografin had a therapeutic effect. A comparison was made between an initial retrospective audit looking at ASBO and a prospective re-audit after applying standards derived from the Bologna guidelines. During re-audit it was found that more patients underwent conservative management and fewer patients had surgery as first line management. In the re-audit, those who had to undergo surgery within/after a period of 72h of conservative management were also fewer. Whether they were managed surgically primarily or after a period of conservative management, the average length of stay was also shorter. In comparison to the preliminary audit, there appeared to be no change in the way that medical history and physical examination was documented during the re-audit. However, there was a marked difference in the use of appropriate blood tests and CT scans. Changes were made successfully following the initial audit results and have been implemented, thus closing the audit loop. This study shows that the use of Gastrografin has decreased the need for surgical intervention in a group of patients with small bowel obstruction.
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Affiliation(s)
- Abhilash Paily
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk, England
| | - Jalpa Kotecha
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk, England
| | - Loveena Sreedharan
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk, England
| | - Bhaskar Kumar
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norfolk, England
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13
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Catena F, De Simone B, Coccolini F, Di Saverio S, Sartelli M, Ansaloni L. Bowel obstruction: a narrative review for all physicians. World J Emerg Surg 2019; 14:20. [PMID: 31168315 PMCID: PMC6489175 DOI: 10.1186/s13017-019-0240-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/10/2019] [Indexed: 12/13/2022] Open
Abstract
Small and large bowel obstructions are responsible for approximately 15% of hospital admissions for acute abdominal pain in the USA and ~ 20% of cases needing acute surgical care. Starting from the analysis of a common clinical problem, we want to guide primary care physicians in the initial management of a patient presenting with acute abdominal pain associated with intestinal obstruction.
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Affiliation(s)
- Fausto Catena
- 1Emergency and Trauma Surgery Department, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | - Belinda De Simone
- 1Emergency and Trauma Surgery Department, Parma University Hospital, Via Gramsci 14, 43126 Parma, Italy
| | | | | | | | - Luca Ansaloni
- Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
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14
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Thornblade LW, Verdial FC, Bartek MA, Flum DR, Davidson GH. The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review. J Gastrointest Surg 2019; 23:846-859. [PMID: 30788717 PMCID: PMC6988581 DOI: 10.1007/s11605-018-4017-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/18/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical training has long been to "never let the sun set on a bowel obstruction" without an operation to rule out and/or treat compromised bowel. However, advances in diagnostics have called into question the appropriate timing of non-emergent operations and expectant management is increasingly used. We performed a systematic review to evaluate the safety and effectiveness of expectant management for adhesive small bowel obstruction (aSBO) compared to early, non-emergent operation. MATERIALS & METHODS We queried PubMed, EMBASE, and Cochrane databases for studies (1990-present) comparing early, non-emergent operations and expectant management for aSBO (PROSPERO #CRD42017057676). RESULTS Of 4873 studies, 29 cohort studies were included for full-text review. Four studies directly compared early surgery with expectant management, but none excluded patients who underwent emergent operations from those having early non-emergent surgery, precluding a direct comparison of the two treatment types of interest. When aggregated, the rate of bowel resection was 29% in patients undergoing early operation vs. 10% in those undergoing expectant management. The rate of successful, non-operative management in the expectant group was 58%. There was a 1.3-day difference in LOS favoring expectant management (LOS 9.7 vs. 8.4 days), and the rate of death was 2% in both groups. CONCLUSION Despite the shift towards expectant management of aSBO, no published studies have yet compared early, non-emergent operation and expectant management. A major limitation in evaluating the outcomes of these approaches using existing studies is confounding by indication related to including patients with emergent indications for surgery on admission in the early operative group. A future study, randomizing patients to early non-emergent surgery or expectant management, should inform the comparative safety and value of these approaches.
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Affiliation(s)
- Lucas W Thornblade
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
| | - Francys C Verdial
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
| | - Matthew A Bartek
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA.
| | - David R Flum
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
| | - Giana H Davidson
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
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Schuster KM, Holena DN, Salim A, Savage S, Crandall M. American Association for the Surgery of Trauma emergency general surgery guideline summaries 2018: acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstruction. Trauma Surg Acute Care Open 2019; 4:e000281. [PMID: 31058240 PMCID: PMC6461136 DOI: 10.1136/tsaco-2018-000281] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 11/27/2018] [Indexed: 12/16/2022] Open
Abstract
In April 2017, the American Association for the Surgery of Trauma (AAST) asked the AAST Patient Assessment Committee to undertake a gap analysis for published clinical practice guidelines in emergency general surgery (EGS). Committee members performed literature searches to catalogue published guidelines for common EGS diseases and also to identify gaps in the literature where guidelines could be created. For five of the most common EGS conditions, acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstruction, we found multiple well-referenced guidelines published by leading professional organizations. We have summarized guideline recommendations for each of these disease states stratified by the AAST EGS anatomic severity score based on these published consensus guidelines. These summaries could be used to help inform evidence-based clinical decision-making, but are intended to be flexible and updatable in real time as further research emerges. Comprehensive guidelines were available for all of the diseases queried and identified gaps most commonly represented areas lacking a solid evidence base. These are therefore areas where further research is needed.
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Affiliation(s)
- Kevin M Schuster
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Daniel N Holena
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ali Salim
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stephanie Savage
- Indiana University Purdue University at Indianapolis, Indianapolis, Indiana, USA
| | - Marie Crandall
- Department of Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
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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.
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Ozturk E, van Iersel M, Stommel MM, Schoon Y, Ten Broek RR, van Goor H. Small bowel obstruction in the elderly: a plea for comprehensive acute geriatric care. World J Emerg Surg 2018; 13:48. [PMID: 30377439 PMCID: PMC6196030 DOI: 10.1186/s13017-018-0208-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 09/24/2018] [Indexed: 12/16/2022] Open
Abstract
Small bowel obstruction is one of the most frequent emergencies in general surgery, commonly affecting elderly patients. Morbidity and mortality from small bowel obstruction in elderly is high. Significant progress has been made in the diagnosis and management of bowel obstruction in recent years. But little is known whether this progress has benefitted outcomes in elderly patients, particularly those who are frail or have a malignancy as cause of the obstruction, and when considering quality of life and functioning as outcomes. In this review, we discuss the specific challenges and needs of elderly in diagnosis and treatment of small bowel obstruction. We address quality of life aspects and explore how the concept of geriatric assessment can be utilized to improve decision-making and outcomes for elderly patients with a small bowel obstruction.
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Affiliation(s)
- Ekin Ozturk
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Marianne van Iersel
- 2Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martijn Mwj Stommel
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Yvonne Schoon
- 2Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands.,3Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Richard Rpg Ten Broek
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Harry van Goor
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Syrmis W, Richard R, Jenkins-Marsh S, Chia SC, Good P. Oral water soluble contrast for malignant bowel obstruction. Cochrane Database Syst Rev 2018; 2018:CD012014. [PMID: 29513393 PMCID: PMC6494190 DOI: 10.1002/14651858.cd012014.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Malignant bowel obstruction (MBO) is a common problem in patients with intra-abdominal cancer. Oral water soluble contrast (OWSC) has been shown to be useful in the management of adhesive small bowel obstruction in identifying patients who will recover with conservative management alone and also in reducing the length of hospital stay. It is not clear whether the benefits of OWSC in adhesive small bowel obstruction are also seen in patients with MBO. OBJECTIVES To determine the reliability of OWSC media and follow-up abdominal radiographs in predicting the success of conservative treatment in resolving inoperable MBO with conservative management.To determine the efficacy and safety of OWSC media in reducing the duration of obstruction and reducing hospital stay in people with MBO. SEARCH METHODS We identified studies from searching Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in Process, Embase, CINAHL, Science Citation Index (Web of Science) and Conference Proceedings Citation Index - Science (Web of Science). We also searched registries of clinical trials and the CareSearch Grey Literature database. The date of the search was the 6 June 2017. SELECTION CRITERIA Randomised controlled trials (RCTs), or prospective controlled studies, that evaluated the diagnostic potential of OWSC in predicting which malignant bowel obstructions will resolve with conservative treatment.RCTs, or prospective controlled studies, that assessed the therapeutic potential of OWSC in managing MBO at any level compared with placebo, no intervention or usual treatment or supportive care. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We assessed risk of bias and assessed the evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS We found only one RCT meeting the selection criteria for the second objective (therapeutic potential) of this review. This study recruited nine participants. It compared the use of gastrografin versus placebo in adult patients with MBO with no indication for further intervention (surgery, endoscopy) apart from standardised conservative management.The overall risk of bias for the study was high due to issues with low numbers of participants, selective reporting of outcomes and a high attrition rate for the intervention arm.Primary outcomesThe included trial was a pilot study whose primary outcome was to test the feasibility for a large study. The authors reported specifically on the number of patients screened, the number recruited and reasons for exclusion; this was not the focus of our review.Due to the low number of participants, the authors of the study decided not to report on our primary outcome of assessing the ability of OWSC to predict the likelihood of malignant small bowel obstruction resolving with conservative treatment alone (diagnostic effect). It also did not report on our primary outcome of rate of resolution of MBO in patients receiving OWSC compared with those not receiving it (therapeutic effect).The study reported that no issues regarding safety or tolerability of either gastrografin or placebo were identified. The overall quality of the evidence for the incidence of adverse events with OWSC was very low, downgraded twice for serious limitations to study quality (high risk of selective reporting and attrition bias) and downgraded once for imprecision (sparse data).Secondary outcomesThe study planned to report on this review's secondary outcome measures of length of hospital stay and time from administration of OWSC to resolution of MBO. However the authors of the study decided not to do so due to the low numbers of patients recruited. The study did not report on our secondary outcome measure of survival times from onset of inoperable MBO until death. AUTHORS' CONCLUSIONS There is insufficient evidence from RCTs to determine the place of OWSC in predicting which patients with inoperable MBO will respond with conservative treatment alone. There is also insufficient evidence from RCTs to determine the therapeutic effects and safety of OWSC in patients with malignant small bowel obstruction.
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Affiliation(s)
- William Syrmis
- St Vincent's Private Hospital, 411 Main Street, Kangaroo Point, Brisbane, Queensland, Australia
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O. Vilz T. In Reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:10. [PMID: 29345231 PMCID: PMC5778401 DOI: 10.3238/arztebl.2018.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Tim O. Vilz
- *Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie Universitätsklinikum Bonn Germany
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Heng S, Hardy J, Good P. A retrospective audit on usage of Diatrizoate Meglumine (Gastrografin ®) for intestinal obstruction or constipation in patients with advanced neoplasms. Palliat Med 2018; 32:294-298. [PMID: 28805119 DOI: 10.1177/0269216317726430] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Intestinal obstruction and constipation are common conditions in patients with advanced neoplasms. Diatrizoate Meglumine has been used in the management of both these conditions without good quality evidence of its effectiveness and safety. AIM This audit aimed to assess the usage, effectiveness and adverse effects of Diatrizoate Meglumine for intestinal obstruction and constipation in patients with advanced neoplasms. DESIGN A retrospective chart review was undertaken. Descriptive statistics were utilised. SETTING/PARTICIPANTS All patients with known advanced neoplasms admitted to Mater Health Services and St Vincent's Private Hospital Brisbane between January 2013 and October 2015; who were administered Diatrizoate Meglumine were included. RESULTS Seventy-one patients received Diatrizoate Meglumine. The most common diagnoses were ovarian or primary peritoneal neoplasms (33.8%). Diatrizoate Meglumine was most commonly used for intestinal obstruction (59.2%). The median dose used per patient episode was 50 mL (range: 15-500 mL). Thirty-two patients (45%) had imaging 4-24 h post-dose with Diatrizoate Meglumine being present in the large intestine in 75% of these images. Intestinal obstruction or constipation resolved in 90% of patients post-dose. CONCLUSION Most clinicians used 50 mL of Diatrizoate Meglumine as a single dose and repeated imaging after 4-24 h. Diatrizoate Meglumine was well tolerated and may be effective in resolving intestinal obstruction and constipation in patients with advanced neoplasms. Quality controlled studies are needed to further guide the use of Diatrizoate Meglumine in intestinal obstruction and constipation in patients with advanced neoplasms.
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Affiliation(s)
- Sharon Heng
- 1 Palliative Care and Supportive Services, Mater Health Services, South Brisbane, QLD, Australia
| | - Janet Hardy
- 2 Mater Health Services Brisbane, Queensland, Australia
| | - Phillip Good
- 3 St Vincent's Private Hospital, Brisbane, Queensland, Australia
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A Systematic Review of the Clinical Presentation, Diagnosis, and Treatment of Small Bowel Obstruction. Curr Gastroenterol Rep 2017; 19:28. [PMID: 28439845 DOI: 10.1007/s11894-017-0566-9] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy. RECENT FINDINGS SBO incidence is about 350,000/annum in the USA. Etiologies include adhesions (65%), hernias (10%), neoplasms (5%), Crohn's disease (5%), and other (15%). Bowel dilatation occurs proximal to obstruction primarily from swallowed air and secondarily from intraluminal fluid accumulation. Dilatation increases mural tension, decreases mucosal perfusion, causes bacterial proliferation, and decreases mural tensile strength that increases bowel perforation risks. Classical clinical tetrad is abdominal pain, nausea and emesis, abdominal distention, and constipation-to-obstipation. Physical exam may reveal restlessness, acute illness, and signs of dehydration and sepsis, including tachycardia, pyrexia, dry mucous membranes, hypotension/orthostasis, abdominal distention, and hypoactive bowel sounds. Severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness suggest advanced SBO, as do marked leukocytosis, neutrophilia, bandemia, and lactic acidosis. Differential diagnosis includes postoperative ileus, narcotic bowel, colonic pseudo-obstruction, mesenteric ischemia, and large bowel obstruction. Medical resuscitation includes intravenous hydration, correcting electrolyte abnormalities, intravenous antibiotics, nil per os, and nasoenteral suction. Abdominal CT with oral and intravenous gastrografin contrast is highly sensitive and specific in detecting/characterizing SBO. SBO usually resolves with medical therapy but requires surgery, preferentially by laparoscopy, for unremitting total obstruction, bowel perforation, severe ischemia, or clinical deterioration with medical therapy. Overall mortality is 10% but increases to 30% with bowel necrosis/perforation. Key point in SBO is early diagnosis, emphasizing abdominal CT; aggressive medical therapy including rehydration, antibiotics, and nil per os; and surgery for failed medical therapy.
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Postoperative enterocutaneous fistula - principles in non-operative approach. Ann Med Surg (Lond) 2017; 24:77-81. [PMID: 29276586 PMCID: PMC5734825 DOI: 10.1016/j.amsu.2017.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/13/2017] [Accepted: 09/17/2017] [Indexed: 11/21/2022] Open
Abstract
Introduction Postoperative enterocutaneous fistulae could constitute a challenge when they occur following an abdominal surgery. Astute application of correct principles in its management is essential for good outcomes. Methods A retrospective review of records of patients with enterocutaneous fistulas managed non-operatively was done. Clinical assessment, anatomic and physiologic classification of fistula, fluid resuscitation, electrolyte correction, parenteral/enteral nutrition, antibiotic use and fistula effluent monitoring, formed the basis of management. Results (4/14)Four out of 14 patients with enterocutaneous fistulae were managed exclusively non-operatively. Their ages ranged between 34 and 63 years. Mean age 46years. All four fistulae occurred postoperatively. Laparatomy for ectopic pregnancy, bowel obstruction constituted the primary surgery. There were two high output cases and two low output cases. Initial parenteral nutrition was employed in two cases while enterals were used solely in two cases. Fistula closure was achieved in all 4 cases at durations ranging from 7 to 16 days, a mean time of 12.5 days. Conclusion Non-operative approach to management for postoperative enterocutaneous fistulas was successful in these cases.
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Weiss A, Sood D, Greenway SE, Tomassi M. Value of gastrografin in adhesive small bowel obstruction. Langenbecks Arch Surg 2017; 402:1233-1239. [PMID: 28770343 DOI: 10.1007/s00423-017-1605-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 07/14/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Small bowel obstruction (SBO) from adhesive disease presents great burden for the healthcare system. Some groups have reported water soluble contrast agents (WSCA) protocols, but published studies are underpowered. This study introduces a WSCA protocol to improve outcomes and streamline patient care. STUDY DESIGN The study ran July 1, 2013-June 30, 2015, at Kaiser Permanente San Diego; protocol started July 1, 2014. Data was collected prospectively, on an intention to treat basis. We excluded patients whose SBO were not due to adhesive disease. Protocol included nasogastric tube, intravenous resuscitation, liquid docusate, and gastrografin study if symptoms persisted at 24 h. Colon contrast determined resolution vs operative consideration. Primary outcomes were operative rates and hospital length of stay (LOS). RESULTS Seven hundred fifteen were patients admitted with SBO; after exclusions there were 261 pre-protocol and 243 protocol patients. One hundred sixty patients resolved within 24 h; 96% of remaining patients stayed on protocol (n = 154). After WSCA protocol began, 15.6% required an operation, compared to 19.8% of pre-protocol patients (NS). The WSCA protocol significantly decreased the time to surgery (2.8 vs 4.88 days, p = 0.03), and the LOS of operated patients (9.51 vs 15.78 days, p = 0.02). CONCLUSIONS A standardized SBO protocol using WSCA significantly decreased time to operation and hospital LOS. This approach improves utilization of resources and may improve outcomes. More work should be done to investigate the positive effects of WSCA protocol for patients with SBO.
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Affiliation(s)
- Anna Weiss
- Brigham and Women's Hospital, Boston, MA, USA.
| | - Divya Sood
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Scott E Greenway
- Department of Surgery, Kaiser Permanente San Diego, San Diego, CA, USA
| | - Marco Tomassi
- Department of Surgery, Kaiser Permanente San Diego, San Diego, CA, USA
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Methodological overview of systematic reviews to establish the evidence base for emergency general surgery. Br J Surg 2017; 104:513-524. [PMID: 28295254 PMCID: PMC5363346 DOI: 10.1002/bjs.10476] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/23/2016] [Accepted: 11/30/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND The evidence for treatment decision-making in emergency general surgery has not been summarized previously. The aim of this overview was to review the quantity and quality of systematic review evidence for the most common emergency surgical conditions. METHODS Systematic reviews of the most common conditions requiring unplanned admission and treatment managed by general surgeons were eligible for inclusion. The Centre for Reviews and Dissemination databases were searched to April 2014. The number and type (randomized or non-randomized) of included studies and patients were extracted and summarized. The total number of unique studies was recorded for each condition. The nature of the interventions (surgical, non-surgical invasive or non-invasive) was documented. The quality of reviews was assessed using the AMSTAR checklist. RESULTS The 106 included reviews focused mainly on bowel conditions (42), appendicitis (40) and gallstone disease (17). Fifty-one (48·1 per cent) included RCTs alone, 79 (74·5 per cent) included at least one RCT and 25 (23·6 per cent) summarized non-randomized evidence alone. Reviews included 727 unique studies, of which 30·3 per cent were RCTs. Sixty-five reviews compared different types of surgical intervention and 27 summarized trials of surgical versus non-surgical interventions. Fifty-seven reviews (53·8 per cent) were rated as low risk of bias. CONCLUSION This overview of reviews highlights the need for more and better research in this field.
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Pujahari AK. Decision Making in Bowel Obstruction: A Review. J Clin Diagn Res 2017; 10:PE07-PE12. [PMID: 28050445 DOI: 10.7860/jcdr/2016/22170.8923] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 09/06/2016] [Indexed: 11/24/2022]
Abstract
Over the last century there have not been significant changes in the anatomical location of obstruction. The age of presentation has increased along with age related co-morbidity. Management has consequently been challenging as risks keep on increasing with advanced age. Hence, clear decision making has become essential in its management. A selective review of the literature pertaining to common age related aetiologies, diagnosis methods leading to standard decision making and treatment of acute intestinal obstruction was done. The same is obtained from randomized controlled studies, meta-analysis and other related evidence based publications. Predicting the conservative or operative management of Bowel Obstruction (BO) is difficult. BO in young age, in unscarred abdomen and Large Bowel Obstruction (LBO) needs early surgery. Decision on surgery should be taken in paediatric patient by second day and preferably between 3-5 days of admission in adults. Higher American Society of Anaesthesiologists (ASA) grade correlates well with the mortalities. In this article, the timing of surgery, methods to avoid bowel resection and type of surgery in various causes are stressfully analysed and discussed.
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Affiliation(s)
- Aswini Kumar Pujahari
- Professor, Department of Surgery and Surgical Gastroenterology, Vydehi Institute of Medical Sciences and Research Institute , Whitefield, Bangalore, India
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Flores-Funes D, Campillo-Soto Á, Pellicer-Franco E, Aguayo-Albasini JL. Uso de café, chicle y gastrografín en el manejo del íleo postoperatorio: revisión de la evidencia actual. Cir Esp 2016; 94:495-501. [DOI: 10.1016/j.ciresp.2016.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 05/06/2016] [Accepted: 05/30/2016] [Indexed: 12/15/2022]
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Paliogiannis P, Delogu L, Contu G, Cambilargiu AL, Mundula A, Sotgiu G, Biddau C, Attene F, Trignano M, Scognamillo F. Small bowel emergencies: two surgical centers’ experience and literature review. Eur Surg 2015. [DOI: 10.1007/s10353-015-0356-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Wang YR, Yu XL, Peng ZY. Evaluation of different small bowel contrast agents by multi - detector row CT. Int J Clin Exp Med 2015; 8:16175-16182. [PMID: 26629131 PMCID: PMC4659020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 07/06/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE This study aims to evaluate the effects of different oral small bowel contrast agents towards the intestinal dilatation and intestinal wall structure exhibition by the abdominal multi - detector row CT (MDCT) examination. METHODS 80 patients were performed the whole abdominal CT examination, then randomly divided into four groups, with 20 patients in each group. 45 minutes before the CT examination, the patients were served with a total of 1800 ml pure water, pure milk, dilute lactulose solution and isotonic mannitol solution, respectively. RESULTS The images were blinded read by two experienced abdominal radiologists in the workstation, the cross-sectional diameters of duodenum, jejunum, proximal and terminal ends of ileum of each patient were measured, then the analysis of variance was performed to analyze the differences in the intestinal dilatation among the experimental groups. The scoring method was used to score the intestinal dilatation and intestinal structure exhibition. The diluted lactulose solution and 2.5% mannitol exhibited the best intestinal dilation degrees. Similarly, the diluted lactulose solution and 2.5% mannitol exhibited the highest scores in the entire small bowel dilatation degree and intestinal structure exhibition. CONCLUSIONS 2.5% osmotic mannitol and the diluted lactulose solution enabled the full dilatation of small bowel, and could clearly exhibit the wall structure.
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Affiliation(s)
- Yong-Ren Wang
- Department of Radiology, Chinese Medical Hospital of YiwuYiwu 322000, China
| | - Xiao-Li Yu
- Department of Radiology, Chinese Medical Hospital of YiwuYiwu 322000, China
| | - Zhi-Yi Peng
- Department of Radiology, The First Affiliated Hospital of Medical College, Zhejiang UniversityHangzhou 310018, China
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Joseph FA, Naughtin SJ. Non-diagnostic use of oral Gastrografin: a frequent source of conflict, with a practical solution. J Med Imaging Radiat Oncol 2014; 59:179-81. [PMID: 25529025 DOI: 10.1111/1754-9485.12270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 11/04/2014] [Indexed: 11/29/2022]
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Sallinen V, Wikström H, Victorzon M, Salminen P, Koivukangas V, Haukijärvi E, Enholm B, Leppäniemi A, Mentula P. Laparoscopic versus open adhesiolysis for small bowel obstruction - a multicenter, prospective, randomized, controlled trial. BMC Surg 2014; 14:77. [PMID: 25306234 PMCID: PMC4198325 DOI: 10.1186/1471-2482-14-77] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 10/03/2014] [Indexed: 02/06/2023] Open
Abstract
Background Laparoscopic adhesiolysis is emerging as an alternative for open surgery in adhesive small bowel obstruction. Retrospective studies suggest that laparoscopic approach shortens hospital stay and reduces complications in these patients. However, no prospective, randomized, controlled trials comparing laparoscopy to open surgery have been published. Methods/Design This is a multicenter, prospective, open label, randomized, controlled trial comparing laparoscopic adhesiolysis to open surgery in patients with computed-tomography diagnosed adhesive small bowel obstruction that is not resolving with conservative management. The primary study endpoint is the length of postoperative hospital stay in days. Sample size was estimated based on preliminary retrospective cohort, which suggested that 102 patients would provide 80% power to detect a difference of 2.5 days in the length of postoperative hospital stay with significance level of 0.05. Secondary endpoints include passage of stool, commencement of enteral nutrition, 30-day mortality, complications, postoperative pain, and the length of sick leave. Tertiary endpoints consist of the rate of ventral hernia and the recurrence of small bowel obstruction during long-term follow-up. Long-term follow-up by letter or telephone interview will take place at 1, 5, and 10 years. Discussion To the best of our knowledge, this trial is the first one aiming to provide level Ib evidence to assess the use of laparoscopy in the treatment of adhesive small bowel obstruction. Trial registration ClinicalTrials.gov identifier:
NCT01867528. Date of registration May 26th 2013.
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Affiliation(s)
- Ville Sallinen
- Department of Abdominal Surgery, Helsinki University Central Hospital, Haartmaninkatu 4, 00029 Helsinki, Finland.
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Abstract
OBJECTIVE To assess the effectiveness of conservative treatment for adhesive small bowel obstruction (ASBO) in children. DESIGN Systematic review of studies involved children with ASBO who received initial conservative/non-operative treatment. SETTING The search was performed in April 2013 using PubMed (see online supplementary file 1), current contents, and the Cochrane database. PARTICIPANTS Children with ASBO. INTERVENTIONS Conservative treatment included nasogastric decompression, parenteral fluids and correction of electrolyte and fluid imbalance. PRIMARY OUTCOME Treatment success. SECONDARY OUTCOMES Length of hospital stay and the time to first feeding after hospital admission. RESULTS 7 studies (six retrospective, one prospective), involving 8-109 patients (age: 1 month to 16 years) treated conservatively, were included in the review. The nature of conservative treatment was generally consistent between studies (nasogastric decompression, parenteral fluids and correction of electrolyte and fluid imbalance), although patients in one study also received Gastrografin. The rate of conservative treatment success ranged from 16% to 75% among the five studies, but one trial showed 0% successful rate. The hospital length of stay ranged from 3 to 6.5 days for conservative treatment (vs 10.2-13 days for operative treatment). The time to first feeding ranged from 31 to 84 h for conservative treatment. CONCLUSIONS In conclusion, in the majority of cases, conservative treatment is an effective means of managing ASBO in children.
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Affiliation(s)
- Lung-Huang Lin
- Departments of Pediatrics, Cathay General Hospital, Taipei, Taiwan
- School of Medicine, FuJen Catholic University, New Taipei City, Taiwan
| | - Chee-Yew Lee
- Departments of Pediatrics, Cathay General Hospital, Taipei, Taiwan
| | - Min-Hsuan Hung
- Department of Pediatrics, Song-Shan Armed Forces General Hospital, Taipei, Taiwan
| | - Der-Fang Chen
- Department of Surgery, Cathay General Hospital, Taipei, Taiwan
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Di Saverio S, Coccolini F, Galati M, Smerieri N, Biffl WL, Ansaloni L, Tugnoli G, Velmahos GC, Sartelli M, Bendinelli C, Fraga GP, Kelly MD, Moore FA, Mandalà V, Mandalà S, Masetti M, Jovine E, Pinna AD, Peitzman AB, Leppaniemi A, Sugarbaker PH, Goor HV, Moore EE, Jeekel J, Catena F. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg 2013; 8:42. [PMID: 24112637 PMCID: PMC4124851 DOI: 10.1186/1749-7922-8-42] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 09/23/2013] [Indexed: 12/19/2022] Open
Abstract
Background In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy. Recommendations In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay. NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended. Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery. Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained. Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery. Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.
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Affiliation(s)
- Salomone Di Saverio
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | | | - Marica Galati
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Nazareno Smerieri
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Walter L Biffl
- Department of Surgery, Denver Health, University of Colorado Health Sciences Denver, Denver Health Medical Center, 777 Bannock Street, Denver CO 80204, USA
| | - Luca Ansaloni
- General Surgery I, Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - Gregorio Tugnoli
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - George C Velmahos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Cino Bendinelli
- Department of Surgery, John Hunter Hospital and University of Newcastle, Locke Bag 1 Hunter Region Maile Centre, Newcastle, NSW 2310, Australia
| | | | - Michael D Kelly
- Upper GI Unit, Department of Surgery, Frenchay Hospital, North Bristol, NHS Trust, Bristol, UK
| | - Frederick A Moore
- Department of Surgery, University of Florida, Gainesville, FL 32610-0254, USA
| | - Vincenzo Mandalà
- Department of General and Emergency Surgery, Associated Hospitals "Villa Sofia - Cervello", Palermo, Italy
| | - Stefano Mandalà
- Department of General and Emergency Surgery, Associated Hospitals "Villa Sofia - Cervello", Palermo, Italy
| | - Michele Masetti
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Elio Jovine
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Antonio D Pinna
- Emergency Surgery Unit, Department of General and Multivisceral Transplant Surgery, S Orsola Malpighi University Hospital, Bologna, Italy
| | - Andrew B Peitzman
- Division of General Surgery, University of Pittsburgh Physicians, Pittsburgh 15213 PA, USA
| | - Ari Leppaniemi
- Emergency Surgery, Department of Abdominal Surgery, Meilahti Hospital, University of Helsinki, Haartmaninkatu 4, 340, Helsinki FIN-00029 HUS, Finland
| | - Paul H Sugarbaker
- Washington Cancer Institute, Washington Hospital Center, Washington, 20010 DC, USA
| | - Harry Van Goor
- Department of Surgery, Radboud University Nijmegen Medical Centre, P.O. Box 9101 6500 HB, Nijmegen, The Netherlands
| | - Ernest E Moore
- Department of Surgery, Denver Health, University of Colorado Health Sciences Denver, Denver Health Medical Center, 777 Bannock Street, Denver CO 80204, USA
| | - Johannes Jeekel
- Department of Surgery, Erasmus University Medical Center, PO Box 2040 3000 CA, Rotterdam, The Netherlands
| | - Fausto Catena
- Emergency Surgery Unit, Department of General and Multivisceral Transplant Surgery, S Orsola Malpighi University Hospital, Bologna, Italy.,Department of Emergency and Trauma Surgery, Maggiore Hospital of Parma, Parma, Italy
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Lee C, Vather R, O’Callaghan A, Robinson J, McLeod B, Findlay M, Bissett I. Validation of the Phase II Feasibility Study in a Palliative Care Setting. Am J Hosp Palliat Care 2012; 30:752-8. [DOI: 10.1177/1049909112471422] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Malignant bowel obstruction (MBO) is common in patients with advanced cancer. Aim: To perform a phase II study to assess the feasibility of conducting a phase III trial investigating the therapeutic value of gastrografin in MBO. Methods: Randomized double-blinded placebo-controlled feasibility study. Participants received 100 mL of either gastrografin or placebo. Results: Over 8 months, 57 patients were screened and 9 enrolled (15.8% recruitment rate). Of the 9 enrolled, 4 received gastrografin (with 2 completing assessment) and 5 received placebo (with 4 completing assessment). Conclusions: It is not feasible to conduct a phase III trial using the same study protocol. This study validates the use of the phase II feasibility study to assess protocol viability in a palliative population prior to embarking on a larger trial.
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Affiliation(s)
- Cindy Lee
- Department of Surgery, The University of Auckland, New Zealand
| | - Ryash Vather
- Department of Surgery, The University of Auckland, New Zealand
| | | | - Jackie Robinson
- Palliative Care Service, Auckland City Hospital, New Zealand
| | - Briar McLeod
- Department of Surgery, The University of Auckland, New Zealand
| | - Michael Findlay
- Discipline of Oncology, The University of Auckland, New Zealand
| | - Ian Bissett
- Department of Surgery, The University of Auckland, New Zealand
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Dayton MT, Dempsey DT, Larson GM, Posner AR. New paradigms in the treatment of small bowel obstruction. Curr Probl Surg 2012; 49:642-717. [PMID: 23057861 DOI: 10.1067/j.cpsurg.2012.06.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Merril T Dayton
- Department of Surgery, SUNY Buffalo, Kaleida Health System, Buffalo, NY, USA
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35
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Abstract
The ability to appropriately construct and care for an ostomy is crucial to good colorectal surgical practice. Enterostomal therapy is critical to the successful management of ostomies and their complications. Although associated with morbidity, a well-constructed ostomy can provide our patients with a good, durable QoL.
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Suo T, Gu X, Andersson R, Ma H, Zhang W, Deng W, Zhang B, Cai D, Qin X. Oral traditional Chinese medication for adhesive small bowel obstruction. Cochrane Database Syst Rev 2012:CD008836. [PMID: 22592734 DOI: 10.1002/14651858.cd008836.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Small bowel obstruction (SBO) is one of the most common emergent complications of general surgery. Intra-abdominal adhesions are the leading cause of SBO. Because surgery can induce new adhesions, non-operative management is preferred in the absence of signs of peritonitis or strangulation. Oral traditional Chinese herbal medicine has long been used as a non-operative therapy to treat adhesive SBO in China. Many controlled trials have been conducted to investigate its therapeutic value in resolving adhesive SBO. OBJECTIVES The aim of this review was to assess the efficacy and safety of oral traditional Chinese medicine (TCM) for adhesive small bowel obstruction. SEARCH METHODS We searched the following databases, without regard to language or publishing restrictions: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Chinese Biomedical Database (CBM), China National Knowledge Infrastructure/Chinese Academic Journals full-text Database (CNKI), and VIP (a full-text database of Chinese journals). The searches were conducted in November 2011. SELECTION CRITERIA Randomised controlled trials and quasi-randomised controlled trials comparing Chinese medicines administered orally, via the gastric canal, or both with a placebo or conventional therapy in participants diagnosed with adhesive SBO were considered. We also considered trials of TCM (oral administration, gastric tube perfusion, or both) plus conventional therapy compared with conventional therapy alone for patients with adhesive SBO. Studies addressing the safety and efficacy of oral traditional Chinese medicinal agents in the treatment of adhesive SBO were also considered. DATA COLLECTION AND ANALYSIS Two authors collected the data independently. We assessed the risk of bias according to the following methodological criteria: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting and other sources of bias. Dichotomous data are presented as risk ratios (OR) and 95% confidence intervals (CI); continuous outcomes are presented as mean differences (MD) and 95% CIs. The data analyses were carried out using Review Manager 5.1. For cases in which necessary information was not reported in the paper, we contacted the primary authors for additional information. MAIN RESULTS Five randomised trials involving 664 participants were analysed. Five different herbal medicines were tested in these trials, including Huo-Xue-Tong-Fu decoction, Xiao-Cheng-Qi-Tang decoction, a combination of Xiao-Cheng-Qi-Tang and Si-Jun-Zi-Tang decoctions, Chang-Nian-Lian-Song-Jie-Tang decoction, and Fufang-Da-Cheng-Qi-Tang decoction. There were variations in the tested herbal compositions and methods of medicine administration. The main outcomes reported in the trials were effects on abdominal pain, abdominal distension, constipation defection, time of first defecation after treatment, and reoperation rate during the course of the disease. Secondary outcomes selected for this review were not available, including complications such as small bowel perfusion (bowel resection, system complications, and other possible complications), length of hospital stay, cost of hospitalisation, and time from admission to surgical intervention. The results of five trials showed that patients receiving TCM combined with conventional therapy seemed to have improved outcomes compared with patients receiving conventional treatment alone (OR 4.24, 95% CI 2.83 to 6.36).However, we cannot conclusively determine the efficacy of TCM in this review due to inadequate reporting, low methodological quality, and the prevalence of various biases in the reviewed studies. Furthermore, because none of the reviewed trials discussed adverse events, we could not evaluate the safety of TCM for adhesive SBO patients. All trials were conducted and published in China. AUTHORS' CONCLUSIONS Although many studies have assessed the use of TCM products for adhesive SBO, most were excluded from this review due to their methodological limitations. This systematic review did not find sufficient evidence to support the objective efficacy and safety of TCM for patients with adhesive SBO. The positive evidence should be interpreted with caution given the insufficient number of studies with large sample sizes, the absence of well-designed, high-quality trials, and the lack of safety information. Therefore, further studies with larger sample sizes and high-quality, randomised, and controlled trials are necessary to produce more accurate and meaningful data on the efficacy of Chinese herbal medicines for adhesive SBO.
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Affiliation(s)
- Tao Suo
- Department of General Surgery, Zhongshan Hospital, Institute of General Surgery, Fudan University, Shanghai, China
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Vettoretto N, Carrara A, Corradi A, De Vivo G, Lazzaro L, Ricciardelli L, Agresta F, Amodio C, Bergamini C, Borzellino G, Catani M, Cavaliere D, Cirocchi R, Gemini S, Mirabella A, Palasciano N, Piazza D, Piccoli M, Rigamonti M, Scatizzi M, Tamborrino E, Zago M. Laparoscopic adhesiolysis: consensus conference guidelines. Colorectal Dis 2012; 14:e208-15. [PMID: 22309304 DOI: 10.1111/j.1463-1318.2012.02968.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Laparoscopic adhesiolysis has been demonstrated to be technically feasible in small bowel obstruction and carries advantages in terms of post-surgical course. The increasing dissemination of laparoscopic surgery in the emergency setting and the lack of concrete evidence in the literature have called for a consensus conference to draw recommendations for clinical practice. METHODS A literature search was used to outline the evidence, and a consensus conference was held between experts in the field. A survey of international experts added expertise to the debate. A public jury of surgeons discussed and validated the statements, and the entire process was reviewed by three external experts. RESULTS Recommendations concern the diagnostic evaluation, the timing of the operation, the selection of patients, the induction of the pneumoperitoneum, the removal of the cause of obstructions, the criteria for conversion, the use of adhesion-preventing agents, the need for high-technology dissection instruments and behaviour in the case of misdiagnosed hernia or the need for bowel resection. CONCLUSION Evidence of this kind of surgery is scanty because of the absence of randomized controlled trials. Nevertheless laparoscopic skills in emergency are widespread. The recommendations given with the consensus process might be a useful tool in the hands of surgeons.
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Affiliation(s)
- N Vettoretto
- Laparoscopic Surgery Unit, M. Mellini Hospital, Chiari, Italy.
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Doorly MG, Senagore AJ. Pathogenesis and clinical and economic consequences of postoperative ileus. Surg Clin North Am 2012; 92:259-72, viii. [PMID: 22414412 DOI: 10.1016/j.suc.2012.01.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Postoperative ileus is a preventable disease with surprising economic consequences. Understanding the triad of dysmotility in conjunction with an enhanced recovery program improves patient outcome, decreases length of stay in hospital, and lowers the cost. Alvimopan and other investigational promotility medications can help attain these goals. Surgeons should avoid labeling all postoperative abdominal distention as ileus, which not only prevents timely diagnosis and treatment of early postoperative small bowel obstruction or acute colonic pseudo-obstruction but also increases patient morbidity and mortality.
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Gastrografin for uncomplicated adhesive small bowel obstruction in children. Pediatr Surg Int 2011; 27:1277-81. [PMID: 21818521 DOI: 10.1007/s00383-011-2963-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE The risk of bowel injury during surgery for small bowel obstruction (SBO) has generated interest in conservative treatment modalities. Few data are available on conservative Gastrografin treatment for SBO in children. METHODS We prospectively included patients with uncomplicated adhesive SBO managed at a pediatric center between March 2009 and September 2010. Patients who were unimproved after 48 h of conservative treatment received 50-100 ml of Gastrografin. If Gastrografin was seen in the cecum on the abdominal radiograph 4-6 h later, feeding was initiated and the patient was discharged on the same day. Each patient was matched to 2 controls on the number of previous SBO episodes. The primary outcome was length of hospital stay (>3 days), and the secondary outcome was time from admission to first feed (>2 days). Both were compared in the two groups using conditional logistic regression. RESULTS The 8 patients admitted for SBO were matched to 16 controls. Gastrografin administration was associated with significantly lower risks of staying in the hospital longer than 3 days (P < 0.10) and waiting more than 2 days before the first feed. CONCLUSION This preliminary study suggests that Gastrografin may be useful for managing adhesive SBO in children.
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40
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Isaksson K, Weber E, Andersson R, Tingstedt B. Small bowel obstruction: early parameters predicting the need for surgical intervention. Eur J Trauma Emerg Surg 2011; 37:155-9. [PMID: 26814954 DOI: 10.1007/s00068-010-0033-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 06/08/2010] [Indexed: 10/19/2022]
Abstract
AIM To study and identify early clinical and radiological findings that could help to predict operative intervention for small bowel obstruction. MATERIALS AND METHODS One hundred and nine consecutive patients with small bowel obstruction who underwent small bowel follow-through examination with Gastrografin(®) during 2005-2006. The patients were divided into an operative group and a non-operative group, n = 44 and 65, respectively. Findings primarily noted were those which were possible to register within 1-4 h from hospital arrival. RESULTS In univariate analyses, factors found to be significantly associated with surgical intervention were no prior abdominal surgery, the presence of radiological differential air fluid levels, and absence of flatulence 24 h prior to admission, CRP > 10 mg/L and dehydration at admission. In multivariate analyses, the presence of dehydration and radiological differentiated air fluid levels were independent predictive factors of significance. Absence of all factors significantly favored non-operative treatment, while operative treatment was significantly favored when two or more factors were present. CONCLUSIONS The presence of two or more early predictive factors as defined above, available at admission, significantly correlates with a likelihood of complete obstruction and the need of surgical intervention.
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Affiliation(s)
- K Isaksson
- Department of Surgery, University of Lund, University Hospital of Lund, 221 85, Lund, Sweden.
| | - E Weber
- Department of Surgery, University of Lund, University Hospital of Lund, 221 85, Lund, Sweden
| | - R Andersson
- Department of Surgery, University of Lund, University Hospital of Lund, 221 85, Lund, Sweden
| | - B Tingstedt
- Department of Surgery, University of Lund, University Hospital of Lund, 221 85, Lund, Sweden
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41
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Catena F, Di Saverio S, Kelly MD, Biffl WL, Ansaloni L, Mandalà V, Velmahos GC, Sartelli M, Tugnoli G, Lupo M, Mandalà S, Pinna AD, Sugarbaker PH, Van Goor H, Moore EE, Jeekel J. Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2011; 6:5. [PMID: 21255429 PMCID: PMC3037327 DOI: 10.1186/1749-7922-6-5] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 01/21/2011] [Indexed: 12/11/2022] Open
Abstract
Background There is no consensus on diagnosis and management of ASBO. Initial conservative management is usually safe, however proper timing for discontinuing non operative treatment is still controversial. Open surgery or laparoscopy are used without standardized indications. Methods A panel of 13 international experts with interest and background in ASBO and peritoneal diseases, participated in a consensus conference during the 1st International Congress of the World Society of Emergency Surgery and 9th Peritoneum and Surgery Society meeting, in Bologna, July 1-3, 2010, for developing evidence-based recommendations for diagnosis and management of ASBO. Whenever was a lack of high-level evidence, the working group formulated guidelines by obtaining consensus. Recommendations In absence of signs of strangulation and history of persistent vomiting or combined CT scan signs (free fluid, mesenteric oedema, small bowel faeces sign, devascularized bowel) patients with partial ASBO can be managed safely with NOM and tube decompression (either with long or NG) should be attempted. These patients are good candidates for Water Soluble Contrast Medium (WSCM) with both diagnostic and therapeutic purposes. The appearance of water-soluble contrast in the colon on X-ray within 24 hours from administration predicts resolution. WSCM may be administered either orally or via NGT (50-150 ml) both immediately at admission or after an initial attempt of conservative treatment of 48 hours. The use of WSCM for ASBO is safe and reduces need for surgery, time to resolution and hospital stay. NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution surgery is recommended. Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not affect recurrence rates or recurrences needing surgery when compared to traditional conservative treatment. Open surgery is the preferred method for surgical treatment of strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach can be attempted using open access technique. Access in the left upper quadrant should be safe. Laparoscopic adhesiolysis should be attempted preferably in case of first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained. Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin can reduce incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.
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Affiliation(s)
- Fausto Catena
- Emergency Surgery Unit, Department of General and Multivisceral Transplant Surgery, S, Orsola Malpighi University Hospital, Bologna, Italy.
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42
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Vallicelli C, Coccolini F, Catena F, Ansaloni L, Montori G, Di Saverio S, Pinna AD. Small bowel emergency surgery: literature's review. World J Emerg Surg 2011; 6:1. [PMID: 21214933 PMCID: PMC3025845 DOI: 10.1186/1749-7922-6-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 01/07/2011] [Indexed: 12/15/2022] Open
Abstract
Emergency surgery of the small bowel represents a challenge for the surgeon, in the third millennium as well. There is a wide number of pathologies which involve the small bowel. The present review, by analyzing the recent and past literature, resumes the more commons. The aim of the present review is to provide the main indications to face the principal pathologies an emergency surgeon has to face with during his daily activity.
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Affiliation(s)
- Carlo Vallicelli
- General, Emergency and Transplant Surgery Dept., Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Coccolini
- General, Emergency and Transplant Surgery Dept., Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Fausto Catena
- General, Emergency and Transplant Surgery Dept., Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Luca Ansaloni
- General and Emergency Surgery Dept., Ospedali Riuniti Hospital, Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Transplant Surgery Dept., Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Antonio D Pinna
- General, Emergency and Transplant Surgery Dept., Sant'Orsola-Malpighi University Hospital, Bologna, Italy
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Boutros C, Espat NJ. Further Uses of Gastrografin in Adhesive Small Bowel Obstruction: Are We Close to a Definitive Answer. J Surg Res 2010; 160:60-2. [DOI: 10.1016/j.jss.2009.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Revised: 04/29/2009] [Accepted: 05/14/2009] [Indexed: 11/16/2022]
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O’Daly BJ, Ridgway PF, Keenan N, Sweeney KJ, Brophy DP, Hill AD, Evoy D, O’Higgins NJ, McDermott EW. Detected peritoneal fluid in small bowel obstruction is associated with the need for surgical intervention. Can J Surg 2009; 52:201-206. [PMID: 19503664 PMCID: PMC2689745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2008] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Predicting the clinical course in adhesional small bowel obstruction is difficult. There are no validated clinical or radiologic features that allow early identification of patients likely to require surgical intervention. METHODS We conducted a retrospective review of 100 patients consecutively admitted to a tertiary level teaching hospital over a 3-year period (2002-2004) who had acute adhesional small bowel obstruction and underwent computed tomography (CT). The primary outcomes that we assessed were conservative management or the need for surgical intervention. We investigated time to physiologic gastrointestinal function recovery as a secondary outcome. We examined independent predictors of surgical intervention in a bivariate analysis using a stepwise logistic regression analysis. RESULTS Of the 100 patients investigated, we excluded 12. Of the 88 remaining patients, 58 (66%) were managed conservatively and 30 (34%) underwent surgery. Peritoneal fluid detected on a CT scan (n = 37) was associated more frequently with surgery than conservative management (46% v. 29%, p = 0.046, chi(2)). Logistical regression identified peritoneal fluid detected on a CT scan as an independent predictor of surgical intervention (odds ratio 3.0, 95% confidence interval 1.15-7.84). CONCLUSION The presence of peritoneal fluid on a CT scan in patients with adhesional small bowel obstruction is an independent predictor of surgical intervention and should alert the clinician that the patient is 3 times more likely to require surgery.
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Affiliation(s)
| | | | | | | | - David P. Brophy
- Department of Radiology, St. Vincent’s University Hospital, Elm Park, Dublin, Ireland
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