Laparoscopic versus open surgical management of adhesive small bowel obstruction: a comparison of outcomes

Minimally Invasive Surgery in Acute Bowel Obstruction: Should It Become the Standard of Care? A Prospective, Single Center, Observational Study

Background/Objectives: This study was conducted to determine whether a structured clinical pathway can help to safely implement minimally invasive surgery (MIS) as the standard approach in surgery for acute bowel obstruction (ABO). Methods: A prospective analysis was performed on consecutive patients undergoing MIS for ABO at a single center in 2021 and 2022. Prior to the study onset, a structured treatment pathway was defined to apply MIS in all patients. The rate of success in the MIS and patient-, surgeon- and outcome-specific parameters with a focus on complication and conversion rates were analyzed. Results: Compared to a historical control group, the conversion rate from MIS to open surgery (OS) nearly doubled from 20.4% to 36.4% (p = 0.14). The complication rate in converted patients was 43.8% vs. 7.15% in non-converted patients (p < 0.05). Conclusions: A structured clinical pathway, including technical standardization and preoperative decisional processes, can be used to implement MIS as a primary surgical treatment in ABO. This is accompanied by high conversion rates and a significant increase in postoperative complications in patients undergoing conversion. Individual decision-making concerning the surgical approach remains paramount to prevent complications and high conversion rates.

Laparoscopic Management of Small Bowel Obstruction Caused by an Adhesive Internal Hernia Following Open Appendicectomy: A Case Report

Acute intestinal obstruction (AIO) is one of the most common emergency surgical presentations, with small bowel obstruction (SBO) accounting for the majority of cases. Here, we present a case of a 68-year-old female patient who presented to the emergency department with signs and symptoms of SBO. Her medical history was unremarkable except for an open appendectomy performed in her 20s. A computed tomography (CT) scan confirmed the diagnosis of SBO with a transition point in the right iliac fossa with no evidence of ischemia. After the failure of conservative management, diagnostic laparoscopy showed that the SBO was found to be secondary to an internal hernia caused by adhesions. The adhesions were released, and the SBO was resolved; the surgery was completed laparoscopically, enhancing the patient's recovery. This case supports the growing evidence that laparoscopy can be a safe and effective approach for managing SBO, even in cases where conservative management fails. With careful patient selection and surgical expertise, laparoscopy can reduce the need for more invasive procedures and improve patient outcomes.

Keys to successful laparoscopic adhesiolysis for adhesive small bowel obstruction: A scoping review

Background

Adhesive small bowel obstruction (ASBO) is a common acute abdominal complication. Although non-surgical treatment is the primary treatment approach, more and more studies show that surgical treatment can reduce the incidence rate. Laparoscopic adhesiolysis (LA) has many advantages of minimally invasive surgery.But not all patients with ASBO are suitable for LA.

Objective

The aim of this scoping review was to summarize the keys to successful LA by analyzing the extensive literature.

Methods

A literature search was conducted in PubMed for articles on laparoscopic treatment of ASBO published between January 2000 and February 2024. This scoping review followed the framework suggested by Arksey and O'Malley for a scoping review.

Results

By analyzing the included studies we found that LA does have many advantages and can be performed safely. However, the prerequisite is to select patients with simple adhesions whenever possible and to focus on reasonable intraoperative measures. To improve the success rate of LA, we summarized the following characteristics of patients: no contraindications related to pneumoperitoneum, few previous abdominal operations (≤2), no pregnancy, bowel dilatation < 4 cm in diameter, simple adhesions, no diffuse peritonitis, no history of abdominal radiotherapy, <24 h of ASBO, limited previous abdominal surgery (appendix, cholecystectomy), no bowel strangulation ischemia, and bowel necrosis or bowel resection required for other reasons. In addition, we also summarized reasonable intraoperative measures.

Conclusions

Laparoscopic adhesiolysis has many advantages.Specific patients can benefit from LA. This scoping review Summarized the conditions for patient screening and reasonable intraoperative measures with the aim of providing a reference for surgeons, thereby ensuring that more patients benefit from LA.

A systematic review of participant descriptors reported in studies of adhesive small bowel obstruction

AIM

Reporting of participant descriptors in studies of adhesive small bowel obstruction (ASBO) can help identify characteristics associated with favourable outcomes and allow comparison with other studies and real-world clinical populations. The aim was to identify the pattern of participant descriptors reported in studies assessing interventions for ASBO.

METHOD

This systematic review was registered with PROSPERO (CRD42021281031) and reported in line with the PRISMA checklist. Systematic searches of Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were undertaken to identify studies assessing operative and non-operative interventions for adults with ASBO. Studies were dual screened for inclusion. Descriptors were categorised into conceptual domains by the research team.

RESULTS

Searches identified 2648 studies, of which 73 were included. A total of 156 unique descriptors were identified. On average, studies reported 12 descriptors. The most frequently reported descriptors were sex, age, SBO aetiology, history of abdominal surgery, BMI and ASA classification. The highest number of descriptors in a single study was 34, compared to the lowest number of descriptors which was one. Pathway factors were the least frequently described domain. Overall, 37 descriptors were reported in just one study.

CONCLUSION

There is a lack of consistency in participant descriptors reported in studies of SBO. Furthermore, a significant proportion of the descriptors were used infrequently. This makes it challenging to assess whether study participants are representative of the wider population. Further work is required to develop a Core Descriptor Set to standardise the reporting of patient characteristics and reduce heterogeneity between studies.

Adhesive small bowel obstruction: predictive factors of laparoscopic failure

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

Contemporary Assessment of Adhesiolysis and Resection for Adhesive Small Bowel Obstruction in the State of New York

BACKGROUND

Adhesive small bowel obstruction (aSBO) is a common surgical problem, with some advocating for a more aggressive operative approach to avoid recurrence. Contemporary outcomes in a real-world setting were examined.

STUDY DESIGN

A retrospective cohort study was performed using the New York Statewide Planning and Research Cooperative database to identify adults admitted with aSBO, 2016-2020. Patients were stratified by the presence of inflammatory bowel disease (IBD) and cancer history. Diagnoses usually requiring resection were excluded. Patients were categorized into four groups: non-operative, adhesiolysis, resection, and 'other' procedures. In-hospital mortality, major complications, and odds of undergoing resection were compared.

RESULTS

58,976 patients were included. 50,000 (84.8%) underwent non-operative management. Adhesiolysis was the most common procedure performed (n = 4,990, 8.46%), followed by resection (n = 3,078, 5.22%). In-hospital mortality in the lysis and resection groups was 2.2% and 5.9% respectively. Non-IBD patients undergoing operation on the day of admission required intestinal resection 29.9% of the time. Adjusted odds of resection were highest for those with a prior aSBO episode (OR 1.29 95%CI 1.11-1.49), delay to operation ≥3 days (OR1.78 95%CI 1.58-1.99), and non-New York City (NYC) residents being treated at NYC hospitals (OR1.57 95%CI 1.19-2.07).

CONCLUSION

Adhesiolysis is currently the most common surgery for aSBO, however nearly one-third of patients will undergo a more extensive procedure, with an increased risk of mortality. Innovative therapies are needed to reduce the risk of resection.

Liberal surgical laparoscopy reduction for acute intussusception: experience from a tertiary pediatric institute

The optimal treatment for acute intussusception has not yet been defined. In this study, we explored whether employing a liberal laparoscopic intervention for intussusception could lead to favorable outcomes. We performed a historical control analysis to evaluate the outcomes associated with this liberal surgical management protocol. This liberal surgical management protocol were revised to incorporate a new protocol centered around the laparoscopic approach. In some cases of acute intussusception, liberal laparoscopic exploration and intervention were undertaken without initial hydrostatic or pneumatic reduction. During the study interval, a retrospective review was conducted on a total of 3086 patients. These were categorized into two groups: 1338 cases before May 2019 (pre-protocol group) and 1748 cases after May 2019 (post-protocol group). Surgical intervention rates in the pre-protoco and post-protocol period were 10.2% and 27.4% respectively (odds ratio [OR] = 0.30 [95% CI 0.25-0.37]; p < 0.001). No significant differences were observed in baseline clinical characteristics or demographic features between the two groups. The duration from admission to operation was longer for the pre-protocol group (p = 0.008) than for the post-protocol group. The post-protocol group demonstrated decreases in both intestinal resection (OR = 1.50 [95% CI 0.96-2.35]; p = 0.048) and total recurrent events (OR = 1.27 [95% CI 1.04-1.55]; p = 0.012) compared to the pre-protocol group. Liberal laparoscopic intervention for intussusception may effectively reduce the risk of intestinal resection and total recurrent events, thereby exhibiting promising outcomes for patients with intussusception.

Laparoscopic adhesiolysis versus open adhesiolysis in acute adhesive small bowel obstruction

Introduction

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

Patients and Methods

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

Results

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

Conclusion

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

Individualization of the best approach for adhesive small bowel obstruction

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is laparoscopic surgery safe and feasible in acute adhesive ileus?

Although the classical surgical treatment of adhesive ileus is performed using the open method, laparoscopic surgery has recently been performed in some centers. This study aimed to discuss the feasibility and role of laparoscopic surgery in the treatment of adhesive small bowel obstruction. In this retrospective study, the data of 830 patients who were operated for ileus in Başkent University Faculty of Medicine, Ankara Hospital, Department of General Surgery between January 2011 and September 2022 were analyzed. Missing data and intraabdominal cancer-related ileus were accepted as exclusion criteria and 648 patients were excluded from the study. The development of adhesion-related ileus and completeness of the data were accepted as inclusion criteria. Data were compared between the 2 groups [open group (OG; 152 cases) and laparoscopic group (LG; 30 cases]). When the patient characteristics were evaluated, it was found that the history of previous abdominal surgery (P < .001) and the number of previous abdominal surgery (P < .001) were statistically significantly higher in OG. Operation time was significantly longer in the LG (P = .022). There were no statistically significant differences between the groups in terms of intraoperative bowel injury (P = .216), bowel resection (P = .284), and stoma creation (P = .331). OG had a significantly higher rate of Clavien-Dindo grade ≥ 3 serious complications (P < .001) and mortality rate (P = .045). The first gas out occurred significantly earlier in the LG (P = .014). Oral intake was initiated earlier in the LG (P = .004). The length of hospital stay was significantly shorter in the LG (P < .001). There was no significant difference between the groups in terms of postoperative ileus, readmission, and reoperation. Laparoscopic surgery can be safely performed for the treatment of selected patients with adhesive small bowel obstruction. In addition, it is advantageous in terms of postoperative recovery.

Post-appendectomy Adhesive Small Intestine Obstruction With Gangrene: A Sinister Case

Intestinal adhesions are fibrotic bands of scar tissue that develop intra-abdominally due to serosal or peritoneal irritation caused during surgery or by severe infections. It may also occur congenitally. It can lead to serious complications such as small bowel obstruction, which is then termed adhesive small bowel obstruction. In this scenario, it can constrict the bowel wall and cause ischemia and necrosis of the affected intestinal segment. Computed tomography imaging may show characteristic signs, such as the "whirl sign" or "fat-bridging sign." Diagnostic laparoscopy or laparotomy can confirm the diagnosis and presence of adhesions. Management of this condition is either conservative or surgical, the latter of which is necessary in the case of intestinal strangulation. While the literature supports the laparoscopic method of adhesiolysis, practically, it may present technical difficulties. Surgeons should employ their clinical judgment in cases where an open procedure may be more beneficial. We present a case of this very occurrence and discuss the risk factors, pathogenesis, diagnostic evaluation, and, finally, the approaches to surgical management of this condition.

Laparoscopic repair of the broad ligament hernia: A case report

INTRODUCTION AND IMPORTANCE

Broad ligament hernia is a rare type of internal hernia caused by the protrusion of viscera through an abnormal defect on the broad ligament. The diagnosis is difficult and challenging. Usually, it requires an urgent laparotomy to avoid intestinal necrosis or even the death of the patient.

CASE PRESENTATION

A 34-year-old woman, with no medical or surgical history, presented to our educational hospital with acute abdominal pain and recurrent vomiting for the last two days. After clinical and radiological investigations, the diagnosis of an internal hernia through the broad ligament was confirmed. An emergent laparoscopic repair was performed and the postoperative course was uneventful.

CLINICAL DISCUSSION

We report a rare case of an internal hernia through the broad ligament and we describe the challenges associated with the preoperative diagnosis and therapeutic approach. The defect in the broad ligament may be unilateral or bilateral and congenital or acquired. There are no specific clinical and radiologic findings. Surgery remains the cornerstone of the treatment.

CONCLUSION

Early diagnosis and rapid management of broad ligament hernia are necessary to prevent catastrophic sequelae. It is important to keep in mind that internal hernia like broad ligament hernia can occur in patients with no surgical history.

Adhesive Small Bowel Obstruction: A Review

Adhesion is a leading cause of small bowel obstruction. Adhesive small bowel obstruction has significant challenges in diagnosis, treatment and prevention with considerable impact on morbidity and socioeconomic burden. Small bowel obstruction caused by adhesion or any other aetiology is clinically indistinguishable due to similar clinical presentation. Computed Tomography scans and water-soluble contrast studies are more specific in diagnosis and possess value in predicting the need for surgery. Surgical management is indicated only in complicated cases or failed conservative treatments with the majority resolving with non-operative management. However, there is no clear-cut consensus about the timing of operative intervention. Meticulous surgical practice is the keystone in preventing adhesion formation despite the availability of numerous pharmacological and surgical strategies. This review aims to update the current knowledge of the pathophysiology of adhesion formation, treatment options and various prevention modalities of adhesive small bowel obstruction.

KEYWORDS

diagnosis; laparotomy; prevention; surgery.

Comprehensively evaluate the short outcome of small bowel obstruction: A novel medical-economic score system

BACKGROUND

Small bowel obstruction (SBO) still imposes a substantial burden on the health care system. Traditional evaluation systems for SBO outcomes only focus on a single element. The comprehensive evaluation of outcomes for patients with SBO remains poorly studied. Early intensive clinical care would effectively improve the short-term outcomes for SBO, however, the full spectrum of the potential risk status regarding the high complication-cost burden is undetermined.

AIM

We aim to construct a novel system for the evaluation of SBO outcomes and the identification of potential risk status.

METHODS

Patients who were diagnosed with SBO were enrolled and stratified into the simple SBO (SiBO) group and the strangulated SBO (StBO) group. A principal component (PC) analysis was applied for data simplification and the extraction of patient characteristics, followed by separation of the high PC score group and the low PC score group. We identified independent risk status on admission via a binary logistic regression and then constructed predictive models for worsened management outcomes. Receiver operating characteristic curves were drawn, and the areas under the curve (AUCs) were calculated to assess the effectiveness of the predictive models.

RESULTS

Of the 281 patients, 45 patients (16.0%) were found to have StBO, whereas 236 patients (84.0%) had SiBO. Regarding standardized length of stay (LOS), total hospital cost and the presence of severe adverse events (SAEs), a novel principal component was extracted (PC score = 0.429 × LOS + 0.444 × total hospital cost + 0.291 × SAE). In the multivariate analysis, risk statuses related to poor results for SiBO patients, including a low lymphocyte to monocyte ratio (OR = 0.656), radiological features of a lack of small bowel feces signs (OR = 0.316) and mural thickening (OR = 1.338), were identified as risk factors. For the StBO group, higher BUN levels (OR = 1.478) and lower lymphocytes levels (OR = 0.071) were observed. The AUCs of the predictive models for poor outcomes were 0.715 (95%CI: 0.635-0.795) and 0.874 (95%CI: 0.762-0.986) for SiBO and StBO stratification, respectively.

CONCLUSION

The novel PC indicator provided a comprehensive scoring system for evaluating SBO outcomes on the foundation of complication-cost burden. According to the relative risk factors, early tailored intervention would improve the short-term outcomes.

Assessing outcomes in laparoscopic vs open surgical management of adhesive small bowel obstruction

BACKGROUND

Small bowel obstruction is typically managed nonoperatively; however, refractory small bowel obstructions or closed loop obstructions necessitate operative intervention. Traditionally, laparotomy has long been the standard operative intervention for lysis of adhesions of small bowel obstructions. But as surgeons become more comfortable with minimally invasive techniques, laparoscopy has become a widely accepted intervention for small bowel obstructions. The objective of this study was to compare the outcomes of laparoscopy to open surgery in the operative management of small bowel obstruction.

METHODS

This is a retrospective analysis of operative small bowel obstruction cases at a single academic medical center from June 2016 to December 2019. Data were obtained from billing data and electronic medical record for patients with primary diagnosis of small bowel obstruction. Postoperative outcomes between the laparoscopic and open intervention groups were compared. The primary outcome was time to return of bowel function. Secondary outcomes included length of stay, 30-day mortality, 30-day readmission, VTE, and reoperation rate.

RESULTS

The cohort consisted of a total of 279 patients with 170 (61%) and 109 (39%) patients in the open and laparoscopic groups, respectively. Patients undergoing laparoscopic intervention had overall shorter median return of bowel function (4 vs 6 days, p = 0.001) and median length of stay (8 vs 13 days, p = 0.001). When stratifying for bowel resection, patients in the laparoscopic group had shorter return of bowel function (5.5 vs 7 days, p = 0.06) and shorter overall length of stay (10 vs 16 days, p < 0.002). Patients in the laparoscopic group who did not undergo bowel resection had an overall shorter median return of bowel function (3 vs 5 days, p < 0.0009) and length of stay (7 vs 10 days, p < 0.006). When comparing surgeons who performed greater than 40% cases laparoscopically to those with fewer than 40%, there was no difference in patient characteristics. There was no significant difference in return of bowel function, length of stay, post-operative mortality, or re-admission laparoscopic preferred or open preferred surgeons.

CONCLUSION

Laparoscopic intervention for the operative management of small bowel obstruction may provide superior clinical outcomes, shorter return of bowel function and length of stay compared to open operation, but patient selection for laparoscopic intervention is based on surgeon preference rather than patient characteristics.

Superior outcomes with double-balloon enteroscopy for small bowel lesion marking followed by intracorporeal as opposed to extracorporeal resection and reconstruction

BACKGROUND

Double-balloon enteroscopy (DBE) is used for the diagnosis and therapy of small bowel disease. Endoscopic sampling and marking small bowel lesions destined for surgery permit intracorporeal resection and reconstruction (IRR), thereby facilitating a complete minimally invasive technique. There are limited data that compare outcomes of IRR to conventional extracorporeal resection and reconstruction (ERR). The purpose of this study was to evaluate the surgical outcomes of patients undergoing pre-operative DBE for lesion marking followed by laparoscopic IRR compared to those undergoing ERR.

METHODS

A retrospective chart review was performed on patients who underwent DBE followed by small bowel resection from 2006 to 2017 at a single tertiary care medical center. IRR was defined as laparoscopic inspection to identify the lesion (previously marked by DBE or by laparoscopic-assisted DBE) followed by intra-abdominal bowel resection and anastomosis with specimen extraction via minimal extension of a laparoscopic port site. ERR was defined as extracorporeal resection and/or reconstruction performed via a conventional or mini-laparotomy abdominal incision.

RESULTS

A total of 82 patients met inclusion criteria and were reviewed. Thirty-two patients (39%) had ERR and 50 patients (61%) had IRR. The most common indications for DBE were small bowel bleeding (76%) and small bowel mass or thickening on prior imaging studies (16%). Successful DBE was higher in the IRR group when compared to the ERR group, but not significantly different (90% vs 75%, p-value 0.07). Patients who underwent IRR had faster bowel function recovery (2 vs 4 days, p < 0.01), shorter time to discharge (3 vs 7 days, p < 0.01), and fewer post-operative complications (10 vs 18; p < 0.01), when compared to the ERR group.

CONCLUSION

DBE successfully facilitated laparoscopic small bowel IRR and this approach was associated with faster return of bowel function, shorter recovery time, and decreased morbidity when compared to ERR.

A Rare Cause of Small Bowel Obstruction: A Case Report

Introduction

Small bowel obstruction is a common surgical emergency abdominal condition in clinical practice. Fecalith is one of the rare causative factors, especially phytobezoars.

Case Report

We report the case of a 66-year-old man admitted with “abdominal pain with vomiting for 1 day.” Enhanced CT of the abdomen suggested incomplete small bowel obstruction. The symptomatic treatment with fasting, fluid replacement, gastrointestinal decompression, and antibiotics was conducted after the patient was admitted to the hospital. After 2 days of treatment, the patient's abdominal pain was not significantly relieved, so a decision was made to perform laparoscopic examination surgery. During surgery, a columnar foreign body was found embedded in the lumen of the small intestine about 10 cm away from the ileocecal region. Combined with the patient's preoperative history of consuming a large number of persimmons, the primary diagnosis of small intestinal fecalith obstruction was considered. We performed an enterotomy to remove the foreign body, and the procedure was uneventful. On postoperative day 7, the patient was successfully discharged.

Conclusion

When we encounter a patient with intestinal obstruction without a history of surgery in our clinical work, we should take a careful history, especially about the consumption of foods that can cause phytoliths. When a patient has consumed a large amount of food that can cause phytobezoars before the abdominal pain, we should diagnostically consider it as phytobezoars intestinal obstruction, which helps to reduce the incidence of misdiagnosis and allows the patient to receive treatment timely and effectively.

Hydromorphone Protects against CO2 Pneumoperitoneum-Induced Lung Injury via Heme Oxygenase-1-Regulated Mitochondrial Dynamics

Various pharmacological agents and protective methods have been shown to reverse pneumoperitoneum-related lung injury, but identifying the best strategy is challenging. Herein, we employed lung tissues and blood samples from C57BL/6 mice with pneumoperitoneum-induced lung injury and blood samples from patients who received laparoscopic gynecological surgery to investigate the therapeutic role of hydromorphone in pneumoperitoneum-induced lung injury along with the underlying mechanism. We found that pretreatment with hydromorphone alleviated lung injury in mice that underwent CO₂ insufflation, decreased the levels of myeloperoxidase (MPO), total oxidant status (TOS), and oxidative stress index (OSI), and increased total antioxidant status (TAS). In addition, after pretreatment with hydromorphone, upregulated HO-1 protein expression, reduced mitochondrial DNA content, and improved mitochondrial morphology and dynamics were observed in mice subjected to pneumoperitoneum. Immunohistochemical staining also verified that hydromorphone could increase the expression of HO-1 in lung tissues in mice subjected to CO₂ pneumoperitoneum. Notably, in mice treated with HO-1-siRNA, the protective effects of hydromorphone against pneumoperitoneum-induced lung injury were abolished, and hydromorphone did not have additional protective effects on mitochondria. Additionally, in clinical patients who received laparoscopic gynecological surgery, pretreatment with hydromorphone resulted in lower serum levels of club cell secretory protein-16 (CC-16) and intercellular adhesion molecule-1 (ICAM-1), a lower prooxidant-antioxidant balance (PAB), and higher heme oxygenase-1 (HO-1) activity than morphine pretreatment. Collectively, our results suggest that hydromorphone protects against CO₂ pneumoperitoneum-induced lung injury via HO-1-regulated mitochondrial dynamics and may be a promising strategy to treat CO₂ pneumoperitoneum-induced lung injury.

The laparoscopy in emergency general surgery (LEGS) study: a questionnaire survey of UK practice

INTRODUCTION

Recent consensus guidelines suggest that the laparoscopic approach may be a useful, safe and feasible approach in emergency general surgery. Despite this, the UK National Emergency Laparotomy Audit (NELA) suggests the rate of laparoscopy is low (9% fully laparoscopic) and slow to increase over time. A European survey found uptake to be variable. This UK survey was therefore undertaken to establish current UK practice and to determine factors affecting implementation.

MATERIALS AND METHODS

A questionnaire survey of currently practising UK consultant general surgeons was carried out by the North West Surgical Research Collaborative, using a secure web-based database maintained by the North West Surgical Trials Centre.

RESULTS

A total of 151 completed questionnaires were returned from 22 UK centres; 18% of respondents were unaware that laparoscopic cases should be reported to NELA. Appendicectomy (97%) and cholecystectomy (87%) were routinely performed laparoscopically. Laparoscopy was infrequently used in perforation, ischaemia or obstructed hernias. There appears to be equipoise regarding laparoscopic compared with open surgery in small-bowel obstruction among all subspecialty emergency general surgeons, in perforated peptic ulcer among upper gastrointestinal surgeons and in Hinchey III diverticulitis among colorectal surgeons.

CONCLUSION

Uptake of laparoscopy in UK emergency general surgery is influenced by surgeon preference, subspecialty, patient and operative factors. Further research into outcomes may help to identify areas of greatest potential benefit. The rate of laparoscopy reported by NELA may be an underestimate due to the 18% of surgeons unaware that laparoscopic cases should be reported, which may affect the validity of analyses performed from this dataset.

Laparoscopy management for spontaneous bladder rupture: a case report

We present a case of a 79-year-old man with lower abdominal pain and negative Blumberg sign. An indwelling bladder catheter was inserted for urinary retention due to a tight phimosis 2 months earlier. A contrast-enhanced computed tomography scan revealed a huge gastrectasia and small bowel distention due to a suspected adherent bridle. The clinical signs and the laboratory tests were highly suspicious for bowel obstruction and emergency surgery was indicated. Exploratory laparoscopy showed a bladder hole tamponade by an ileum loop. The perforation was sutured laparoscopically and the patient was discharged on the 14th postoperative day. In our case, emergency laparoscopic exploration was useful for the diagnosis and the treatment of spontaneous bladder rupture. We hope this case report can be useful to give these patients better outcomes. Notably we would like to emphasize that the presence of a urinary catheter can be a risk factor for intraperitoneal bladder rupture.

Laparoscopic versus open approach for adhesive small bowel obstruction, a systematic review and meta-analysis of short term outcomes

BACKGROUND

Adhesive small bowel obstruction (ASBO) is one of the most frequent causes of emergency hospital admissions and surgical treatment. Current surgical treatment of ASBO consists of open adhesiolysis. With laparoscopic procedures rising, the question arises if laparoscopy for ASBO is safe and results in better patient outcomes. Although adhesiolysis was among the first surgical procedures to be approached laparoscopically, uncertainty remains about its potential advantages over open surgery. Therefore, we performed a systematic review and meta-analysis on the benefits and harms of laparoscopic surgery for ASBO.

METHODS

A systematic literature review was conducted for articles published up to May 2019. Two reviewers screened all articles and did the quality assessment. Consecutively a meta-analysis was performed. To reduce selection bias, only matched studies were used in our primary analyses. All other studies were used in a sensitivity analyses. All the outcomes were measured within the 30th postoperative day. Core outcome parameters were postoperative mortality, iatrogenic bowel perforations, length of postoperative stay [days], severe postoperative complications, and early readmissions. Secondary outcomes were operative time [min], missed iatrogenic bowel perforations, time to flatus [days], and early unplanned reoperations.

RESULTS

In our meta-analysis, 14 studies (participants = 37.007) were included: 1 randomized controlled trial, 2 matched studies, and 11 unmatched studies. Results of our primary analyses show no significant differences in core outcome parameters (postoperative mortality, iatrogenic bowel perforations, length of postoperative stay, severe postoperative complications, early readmissions). In sensitivity analyses, laparoscopic surgery favored open adhesiolysis in postoperative mortality (relative risk [RR], 0.36; 95% CI, 0.29-0.45), length of postoperative hospital stay (mean difference [MD], -4.19; 95% CI, -4.43 to -3.95), operative time (MD, -18.19; 95% CI, -20.98 to -15.40), time to flatus (MD, -0.98; 95% CI, -1.28 to -0.68), severe postoperative complications (RR, 0.51; 95% CI, 0.46-0.56) and early unplanned reoperations (RR, 0.82; 95% CI, 0.70-0.96).

CONCLUSION

Results of this systematic review indicate that laparoscopic surgery for ASBO is safe and feasible. Laparoscopic surgery is not associated with better or worse postoperative outcomes compared with open adhesiolysis. Future research should focus on the correct selection of those patients who are suitable for laparoscopic approach and may benefit from this approach.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis, Level III.

Nasogastric tube after small bowel obstruction surgery could be avoided: a retrospective cohort study

PURPOSE

The safety and feasibility of early removal of nasogastric tube (NGT) after small bowel obstruction (SBO) surgery have not yet been assessed. Such a practice could allow to implement enhanced recovery after surgery (ERAS) protocols after acute SBO surgery. The aims of this study were to assess the safety of early NGT removal by comparing the short-term outcomes of patients with postoperative NGTs and those with no postoperative NGT.

METHODS

All patients undergoing surgery for strangulation or adhesive SBO between January the 1st of 2014 and December the 31st of 2017 were retrospectively included.

RESULTS

Among the 123 included, NGT was removed immediately after the end of the procedure in 26 cases (21.1%) and 19 patients required NGT replacement (15.4%). In univariate analysis, early removal of NGT was significantly associated with a reduction of overall morbidity, severe morbidity and postoperative ileus occurrence. Multivariate analysis confirmed that NGT left in place was a risk factor for postoperative ileus [Odd Ratio (OR) 4.9, Confidence Interval (CI) 95% 1.3-19.2; p = 0.02], while it has no incidence on severe morbidity.

CONCLUSIONS

Early NGT removal after ASBO surgery seemed to be feasible, safe and efficient, at least in selected patients. This primary study represents the initial foundations for building the implementation of ERAS protocols after ASBO surgery.

Laparoscopic vs open surgery for patients with strangulated small bowel obstruction

BACKGROUND

Recent reports revealed that laparoscopic adhesiolysis is a feasible procedure for patients with adhesive small bowel obstruction (SBO). However, the feasibility of laparoscopic surgery for strangulated SBO has not been investigated in detail.

METHODS

Ninety-six patients who underwent surgery for strangulated SBO between April 2008 and September 2019 were included. Of these, 49 patients were intended to undergo laparoscopic surgery, while the other 47 underwent open surgery from the first. Comparisons were made between the patients who underwent laparoscopic and open surgery in the patients with intestinal resection and without resection, respectively.

RESULTS

In the resection group, eight patients (50.0%) who underwent laparoscopic surgery required conversion to open surgery. Perioperative outcomes were not statistically different between laparoscopic and open surgery except for postoperative use of continuous infusion of an analgesic agent or epidural anesthesia (P = .008). In the non-resection group, five patients (15.1%) who underwent laparoscopic surgery required conversion. Time from surgery to ingestion (P = .025) and postoperative use of continuous infusion of an analgesic agent or epidural anesthesia (P < .001) were significantly favorable in the laparoscopic group. In the patients who underwent laparoscopic surgery, white blood cell count was >12 000/μL (P = .024, odds ratio = 7.569) and intestinal resection (P = .026, odds ratio = 5.19) were found by logistic regression analysis to be independent risk factors for conversion to open.

CONCLUSIONS

Laparoscopic surgery yields superior outcomes in patients without a requirement of intestinal resection. Laparoscopic surgery was considered as a first-choice strategy in selected patients with strangulated SBO.

Delayed bowel obstruction after seat belt injury: a case report

BACKGROUND

Delayed bowel obstruction due to seat belt injury is extremely rare. The delayed onset of nonspecific symptoms makes a timely diagnosis difficult. A deep understanding of the characteristics of this condition is helpful for early diagnosis and treatment.

CASE PRESENTATION

A 39-year-old male was transferred to our hospital from another hospital complaints of progressive abdominal distension and severe weakness. In the previous hospital, he was diagnosed with "adult megacolon" and was recommended for surgical treatment. In our hospital, he was diagnosed with delayed bowel obstruction due to seat belt injury and underwent surgical intervention. Following laparoscopic adhesiolysis and resection of the narrow small intestine, his symptoms improved rapidly, and he was discharged.

CONCLUSION

Delayed bowel obstruction due to seat belt injury may present clinical symptoms any time after the injury. Imaging examination, ileus tube and small colonoscopy may provide us with valuable cues for the diagnosis and treatment of delayed bowel obstruction, and laparoscopy may be an alternative approach in surgical intervention.

Small Bowel Obstruction: the Sun Also Rises?

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.

Aspect of laparoscopic treatment of patients with adhesive small bowel obstruction (review of literature)

Nowadays, adhesive small bowel obstruction (ASBO) is a disease characterized by the stable increase in the number of patients, a significant level of postoperative complications, and a high risk of disability and death. The objective of the article was the research and analysis of relevant data of video laparoscopic treatment of patients with ASBO and possible postoperative complications. A small percentage of complications in clinical centers with a large flow of patients of this profile and rapid postoperative recovery of patients promote the active introduction of laparoscopic adhesiolysis in practical medicine. The analysis of foreign and domestic literature showed that the faithful adherence of indications for application of the technique for resolving intestinal obstruction and restoring passage through the gastrointestinal tract allows to achieve better results and avoid iatrogenic and infectious complications. Thus, laparoscopic treatment can and should be the operation of choice only in a carefully selected group of patients (the first manifestation of ASBO, the absence of pronounced ischemic changes in the intestinal wall and (or) the predicted presence of a small number of peritoneal adhesions), in all other cases, the use of laparotomy is indicated. Currently, there is a clear trend towards an increasing recognition and use of laparoscopy in surgical practice. It is becoming the preferred choice in clinical centers with extensive experience in the treatment of patients with ASBO due to an insignificant percentage of complications and a rapid postoperative recovery.

Evaluation of laparoscopic surgery for small bowel obstruction and factors related to outcomes

Introduction

In recent years, laparoscopic surgery (LS) has been performed for small bowel obstruction (SBO). However, the indications and short-term and long-term outcomes of LS for SBO have not yet been established.

Aim

To evaluate the usefulness of LS for SBO compared to open surgery (OS), as well as to identify risk factors for poor outcomes after LS.

Material and methods

A total of 105 patients who underwent surgery for SBO were divided into OS (n = 64) and LS (n = 41) groups, and propensity score-matched analysis was used to compare the short-term and long-term outcomes of the groups. Risk factors for conversion to OS, postoperative complications, and intraoperative bowel injury in LS were also identified.

Results

The incidences of surgical site infection and postoperative ileus were significantly lower in the LS group. The incidence of recurrent bowel did not differ significantly between the two groups. Prior bowel obstruction was a risk factor for conversion of LS to OS (odds ratio (OR) = 24.79, p = 0.0025). Bowel diameter was a risk factor for postoperative complications (OR = 1.50, 95% CI: 1.01–2.22) and for bowel injury (OR = 1.33, 95% CI: 1.05–1.67).

Conclusions

LS for SBO had better postoperative short-term outcomes than OS. The outcomes of LS for SBO were significantly affected by prior bowel obstruction and bowel diameter.

Adhesive small bowel obstruction - an update

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.

Clinical factors associated with success in applying laparoscopy in the management of small bowel obstruction at a tertiary care center

BACKGROUND

Minimally invasive techniques have become standard approaches for many common surgical problems. However, the routine use of laparoscopy in the management of small bowel obstruction (SBO) has yet to be fully standardized. The objective of this study was to determine clinical factors associated with success of laparoscopy in managing SBO.

METHODS

A retrospective cohort study was conducted by identifying all patients admitted to a large tertiary center with a diagnosis of SBO from 2014 to 2016. The operative cases were stratified by surgical approach: laparoscopy, laparoscopy converted to open, or laparotomy. Univariable analysis compared patient demographics and comorbidities between the laparoscopic and laparoscopic converted to open group. The primary outcome was successful laparoscopic procedure in the management of SBO, defined as resolution of SBO, and no conversion from laparoscopic to open procedures. Student's t test or Pearson's χ² test were used to assess associations between factors and primary outcome.

RESULTS

A total of 227 adult patients admitted with a diagnosis of SBO received operative intervention. There were 40 successful laparoscopic cases (52.6%) and 36 failed laparoscopic cases (47.4%). With the exception of an association between success of laparoscopy and BMI, the results demonstrated no other demographic or clinical differences among the successful versus failed laparoscopic groups.

CONCLUSIONS

Laparoscopy is effective in treating SBOs due to various etiologies including single band or multiple adhesions, hernias, or masses. Other than BMI, there was no single predictor of success or failure with laparoscopy. Therefore, we conclude that perhaps all patients requiring operative treatment for SBO deserve consideration for a diagnostic laparoscopy.

The role of the laparoscopic approach in the surgical management of acute adhesive small bowel obstruction

Background

Postoperative adhesions represent 75% of all acute small bowel obstructions. Although open surgery is considered the standard approach for adhesiolysis, laparoscopic approach is gaining popularity.

Methods

A retrospective study with data from a prospectively maintained data base of all patients undergoing surgical treatment for adhesive small bowel obstruction (ASBO) from January 2007 to May 2016 was conducted. Postoperative outcomes comparing open vs laparoscopic approaches were analysed. An intention to treat analysis was performed. The aim of the study was to evaluate the potential benefits of the laparoscopic approach in the treatment of ASBO.

Results

262 patients undergoing surgery for ASBO were included. 184 (70%) and 78 (30%) patients were operated by open and laparoscopic approach respectively. The conversion rate was 38.5%. Patients in the laparoscopic group were younger (p < 0.001), had fewer previous abdominal operations (p = 0.001), lower ASA grade (p < 0.001), and less complex adhesions were found (p = 0.001). Operative time was longer in the open group (p = 0.004). Laparoscopic adhesiolysis was associated with a lower overall complication rate (43% vs 67.9%, p < 0.001), lower mortality (p = 0.026), earlier oral intake (p < 0.001) and shorter hospital stay (p < 0.001). Specific analysis of patients with single band and/or internal hernia who did not need bowel resection, also demonstrated fewer complications, earlier oral intake and shorter length of stay. In the multivariate analysis, the open approach was an independent risk factor for overall complications compared to the laparoscopic approach (Odds Ratio = 2.89; 95% CI 1.1–7.6; p = 0.033).

Conclusions

Laparoscopic management of ASBO is feasible, effective and safe. The laparoscopic approach improves postoperative outcomes and functional recovery, and should be considered in patients in whom simple band adhesions are suspected. Patient selection is the strongest key factor for having success.

Laparoscopic versus open adhesiolysis for adhesive small bowel obstruction (LASSO): an international, multicentre, randomised, open-label trial

BACKGROUND

Although laparoscopic adhesiolysis for adhesive small bowel obstruction is being done more frequently, it is not widely accepted due to the lack of supporting evidence of its superiority over an open approach and concerns regarding its benefits. We aimed to investigate whether laparoscopic adhesiolysis was a superior treatment for adhesive small bowel obstruction compared with an open approach in terms of length of postoperative hospital stay and morbidity.

METHODS

In this international, multicentre, parallel, open-label trial, we randomly assigned patients (1:1) aged 18-95 years who had adhesive small bowel obstruction that had not resolved with conservative management to have either open or laparoscopic adhesiolysis. The study was done in five academic university hospitals and three community (central) hospitals in two countries (Finland [n=3 academic university hospitals; n=3 community hospitals] and Italy [n=2 academic university hospitals]). We included only patients with high likelihood of a single adhesive band in the trial; additionally, patients who had an anaesthesiological contraindication, were pregnant, living in institutionalised care, or who had a hospital stay of more than 1 week before the surgical consultation were excluded from the trial. The randomisation sequence was generated using block randomisation, with randomly varied block sizes and stratified according to centre. The primary outcome was postoperative length of hospital stay assessed at time of discharge in the modified intention-to-treat population.

FINDINGS

Between July 18, 2013, and April 9, 2018, 566 patients were assessed for eligibility, of whom 104 patients were randomly assigned to the open surgery group (n=51) or to the laparoscopy group (n=53). Of these patients, 100 were included in the modified intention-to-treat analyses (49 in the open surgery group; 51 in the laparoscopy group). The postoperative length of hospital stay for open surgery group was on average 1·3 days longer than that in the laparoscopy group (geometric mean 5·5 days [range 2-19] vs 4·2 days [range 1 -20]; ratio of geometric means 1·31 [95% CI 1·06-1·61]; p=0·013). 21 (43%) patients in the open surgery group and 16 (31%) patients in the laparoscopy group had postoperative complications (Clavien-Dindo any grade) within 30 days (odds ratio 0·61 [95% CI 0·27-1·38]; p=0·23). One patient died in each group within 30 days.

INTERPRETATION

Laparoscopic adhesiolysis provides quicker recovery in selected patients with adhesive small bowel obstruction than open adhesiolysis.

FUNDING

Vatsatautien Tutkimussäätiö Foundation, Mary and Georg Ehrnrooth's Foundation, Martti I Turunen Foundation, and governmental (Finland) competitive research funds (EVO/VTR/TYH).

Laparoscopic versus open surgery for adhesional small bowel obstruction: a systematic review and meta-analysis of case-control studies

BACKGROUND

Small bowel obstruction (SBO) due to adhesions is a common acute surgical presentation. Laparoscopic adhesiolysis is being performed more frequently. However, the clear benefits of laparoscopic adhesiolysis (LA) compared with traditional open adhesiolysis (OA) remain uncertain. The aim of this study was to compare the outcomes of LA versus OA for SBO due to adhesions.

METHODS

A systemic literature review was conducted using PRISMA guidelines. A search was conducted using MEDLINE, EMBASE, PubMed and Cochrane Databases of all randomised controlled trials (RCT) and case-controlled studies (CCS) that compared LA with OA for SBO. Data were extracted using a standardised form and subsequently analysed.

RESULTS

There were no RCT. Data from 18 CCS on 38,927 patients (LA = 5,729 and OA = 33,389) were analysed. A meta-analysis showed that LA for SBO has decreased overall mortality (LA = 1.6% vs. OA = 4.9%, p < 0.001) and morbidity (LA = 11.2% vs. OA = 30.9%, p < 0.001). Similarly, the incidences of specific complications are significantly lower in the LA group. There are significantly lower reoperation rate (LA = 4.5% vs. OA = 6.5%, p = 0.017), shorter average operating time (LA = 89 min vs. OA = 104 min, p < 0.001) and a shorter length of stay (LOS) (LA = 6.7 days vs. OA = 11.6 days, p < 0.001) in the LA group. In the CCS, there is likely to be a selection bias favouring less complex adhesions in the LA group that may contribute to the better outcomes in this group.

CONCLUSIONS

Although there is a probable selection bias, these results suggest that LA for SBO in selected patients has a reduced mortality, morbidity, reoperation rate, average operating time and LOS compared with OA. LA should be considered in appropriately selected patients with acute SBO due to adhesions.

Incarcerated obturator hernia treated using a hybrid laparoscopic and anterior preperitoneal approach: A case report

Obturator hernia (OH) is a rare cause of bowel obstruction. Although several surgical approaches, including the laparoscopic approach, have been reported to date, a standard approach for treating OH has not been established. A 101-year-old woman who presented with constipation and vomiting was admitted to our hospital. CT revealed an incarcerated small bowel within the left obturator foramen, and a diagnosis of left-sided incarcerated OH with small bowel ileus was made. With the patient under general anesthesia, exploratory laparoscopy was performed; we identified an OH with an incarcerated small bowel, which was judged viable after hernia reduction. We repaired the hernia using an anterior preperitoneal approach under laparoscopic assistance and placed a prosthetic mesh over the obturator foramen. The patient recovered with no postoperative complications and was discharged on postoperative day 4. A hybrid laparoscopic and anterior preperitoneal approach is safe and effective for treating an incarcerated OH in an elderly patient.

Revised cardiac risk index poorly predicts cardiovascular complications after adhesiolysis for small bowel obstruction

BACKGROUND

The number of patients undergoing preoperative risk stratification in the United States is expected to increase as the population ages. A large percentage of patients undergo some form of preoperative testing, and society guidelines suggest that up to 50% of the testing in lower risk surgical subgroups is unnecessary. The Revised Cardiac Risk Index and the risk calculator of the American College of Surgeons National Surgical Quality Improvement Program are widely used tools as the first step of preoperative cardiac evaluation. The Revised Cardiac Risk Index was developed to fill a need for objective perioperative cardiac risk evaluation. Despite the ease of use of Revised Cardiac Risk Index, it is uncertain if the stratification is accurate for surgical patients because its accuracy in large surgical samples has not been tested. With the National Surgical Quality Improvement Program risk calculator having excellent accuracy in estimating cardiac complications (area under the receiver operating characteristic 0.895), a unique opportunity to test the predictive accuracy of postsurgical cardiac events became available. The purpose of this study is to determine the accuracy of the Revised Cardiac Risk Index for predicting cardiovascular complications after adhesiolysis for small bowel obstruction.

METHODS

From 2005 to 2015, 34,032 cases of open or laparoscopic adhesiolysis (Current Procedural Terminology codes 44005 and 44180) for small bowel obstruction (International Classification of Diseases, 10th edition [ICD-10]) were analyzed using the National Surgical Quality Improvement Program dataset. Revised Cardiac Risk Index estimates were calculated for each case and compared to reported cardiovascular complications (myocardial infarction or cardiac arrest) using univariable logistic regression. Overall predictive accuracy was assessed by measuring model discrimination (area under the receiver operating characteristic) and model calibration (Hosmer-Lemeshow chi-squared statistics).

RESULTS

Although the Revised Cardiac Risk Index predicted cardiovascular complications with an odds ratio of 2.3 and a 95% confidence interval of 1.9 to 2.8 (P < .001) and the Hosmer-Lemeshow chi-square was significant (0.22, P = 0.64), the area under the receiver operating characteristic was poor (0.63, 95% confidence interval 0.59-0.67).

CONCLUSION

Despite its relative simplicity, the Revised Cardiac Risk Index performed poorly as a predictor of cardiovascular complications after adhesiolysis for small bowel obstruction. These findings question the utility of the Revised Cardiac Risk Index in this patient population. Future studies should aim to develop models that are computationally simple while retaining predictive accuracy.

Laparoscopic adhesiolysis: not for all patients, not for all surgeons, not in all centres

ASBO is a common cause of emergency surgery and the use of laparoscopy for the treatment of these patients is still under debate and conflicting results have been published, in particular regarding the high risk of iatrogenic bowel injury. In fact, although over the last few years there has been an increasing enthusiasm in the surgical community about the advantages and potential better outcomes of laparoscopic management of adhesive small bowel obstruction (ASBO), recently published studies have introduced a significant word of caution. From 2011 in our centre, we have started to systematically approach ASBO in carefully selected patients with a step-by-step standardized laparoscopic procedure, developed and performed by a single operator experienced in emergency laparoscopy, collecting data in a prospective database. Inclusion criteria were: stable patients (without diffuse peritonitis and/or septic shock with suspicion of bowel perforation), CT scan findings consistent with a clear transition point and therefore suspected to have a single obstructing adhesive band. Patients with diffuse SB distension in the absence of a well-defined transition point and suspected to have diffuse matted adhesions (based on their surgical history and radiological findings) should be initially managed conservatively, including gastrografin challenge. Up to date, 83 patients were enrolled in the study. The rate of iatrogenic full-thickness bowel injury was 4/83 (4.8%); two of these cases were managed with simple repair and the other two required bowel resection and anastomosis. Conversion to open was performed in 3/4 of these cases, whereas in one a repair of the full-thickness injury was completed laparoscopically. All the iatrogenic injuries were detected intraoperatively and none of the reoperations that occurred in this series were due to missed bowel injuries. At 30 days follow-up, none reported incisional hernias or SSI or death. With the described accurate selection of patients, the use of such standardized step-by-step technique and in the presence of dedicated operating surgeons with advanced emergency surgery laparoscopic expertise, such procedure can be safe and feasible with multiple advantages in terms of morbidity and LOS. A careful preoperative selection of those patients who might be best candidates for laparoscopic adhesiolysis is needed. The level of laparoscopic expertise can also be highly variable, and not having advanced surgical expertise in the specific subspecialty of emergency laparoscopy, ultimately resulting in performing standardized procedures with proper careful and safe step-by-step technique, is highly recommended.

Bowel obstruction caused by broad ligament hernia sucessfully repaired by laparoscopy

Internal hernais are rare bowel obstructions. We present a case of small bowel obstruction in a 37-year-old woman caused by internal herniation through a defect in broad ligament, which was managed by laparoscopic surgery.

Role of Laparoscopic Management for Postgastrectomy Complications

BACKGROUND

The role of laparoscopy for the management of various types of postgastrectomy complications has not yet been well studied. We describe laparoscopic management of postgastrectomy complications and present a comparison between laparoscopy and other modalities in terms of basic characteristics and postreoperation clinical course.

MATERIALS AND METHODS

We studied 82 patients with postgastrectomy complications (Clavien-Dindo grade ≥IIIa) at a single institution between April 2009 and November 2016. We excluded 15 patients with pulmonary, wound-related, and/or ambiguous complications and eventually studied 67 patients who were divided into nonoperative intervention (NI), laparoscopic reoperation (LR), and open reoperation (OR) groups. Clinicopathological characteristics and surgical outcomes were compared.

RESULTS

Among the 67 patients studied, 31, 21, and 15 belonged to the NI, LR, and OR groups, respectively. Complications included bleeding in 29, leakage in 26, intestinal obstruction in 6, and intra-abdominal abscesses in 6 patients. Among the 21 patients in the LR group, bleeding was reported in 11, leakage in 5, intestinal obstruction in 3, and intra-abdominal abscesses in 2 patients. No significant differences were observed between the groups in terms of clinicopathological characteristics. Regarding surgical outcomes, the NI and LR groups required a mean of 11 days before discharge-a period that was significantly shorter than that required by the OR group (20.5 ± 14.3 days). All patients belonging to the LR group were successfully treated and discharged 11.3 ± 6.0 days after reoperation.

CONCLUSIONS

Laparoscopic management of postgastrectomy complications is a safe and effective procedure primarily because it is associated with a smaller incision, more rapid recovery, and shorter length of hospitalization than that associated with an open laparotomy.

Laparoscopy in small bowel obstruction - current status - review

Introduction

Acute small bowel obstruction (SBO) is an urgent medical condition. Its diagnosis is based mainly on a clinical examination followed by confirmatory simple routine radiological examinations such as plain X-ray of the abdominal cavity or computed tomography (CT). However, a real surgical challenge is not a decision whether to perform a surgery, but a decision when and how to perform it.

Aim

To determine the place of laparoscopy in contemporary management of acute SBO based on the current literature.

Material and methods

A review of the literature based on the Medline database and including mainly the period of 2013–2017 was performed.

Conclusions

With regard to SBO, laparoscopy is a technique showing its advantages resulting from a minimally invasive approach. However, SBO is still a condition where the use of laparoscopy is limited mainly to selected cases such as SBO caused by single adhesions or foreign bodies. A basic limitation of using this technique is advanced and complicated SBO and lack of sufficient technical skills of the surgeon.

A retrospective study of laparoscopic surgery for small bowel obstruction

Background

Open laparotomy is widely accepted as the standard surgical treatment for small bowel obstruction (SBO). However, laparoscopic surgery has recently become a treatment option. There is no consensus on the appropriate settings for the laparoscopic treatment of SBO. The purpose of this study is to evaluate the outcomes of laparoscopic surgery for SBO.

Patients and methods

From January 2012 to May 2016, 48 consecutive patients underwent surgical treatment for SBO in our department. We retrospectively reviewed these cases and compared the features and the outcomes between laparoscopic and open surgery.

Results

Thirty-four and 14 patients underwent open surgery and laparoscopic surgery, respectively. Four of the laparoscopic cases (28.6%) were converted to open surgery. Laparoscopic surgery tended to be associated with a shorter operative time than open surgery (p = 0.066). The first postoperative oral intake was significantly earlier in patients who underwent laparoscopic surgery (p = 0.044). The duration of hospitalization after surgery and the rates of postoperative complications did not differ to a statistically significant extent. Laparoscopic treatment was accomplished in 7 out of 8 cases (87.5%) with SBO due to band occlusion.

Conclusion

Laparoscopic surgery for SBO is less invasive than open surgery and is equally feasible in selected patients. SBO due to band occlusion may be a preferable indication for laparoscopic surgery. In order to confirm the safety of laparoscopic treatment, and to clarify the appropriate settings for laparoscopic surgery for SBO, it will be necessary to perform further studies in a larger population and with a long follow-up period.

•

Surgical treatment for small bowel obstruction in 48 patients were retrospectively reviewed.

•

Laparoscopic surgery was performed in 14 patients, and 4 cases were converted to open surgery.

•

Laparoscopic surgery is less invasive than open surgery and is equally feasible in selected patients.

•

Band occlusion may be a preferable indication to laparoscopic surgery.

Laparoscopic versus Open Surgery for Acute Adhesive Small-Bowel Obstruction: A Propensity Score-Matched Analysis

BACKGROUND AND AIMS

The laparoscopic approach has been increasingly used to treat adhesive small-bowel obstruction. The aim of this study was to compare the outcomes of a laparoscopic versus an open approach for adhesive small-bowel obstruction.

MATERIAL AND METHODS

Data were retrospectively collected on patients who had surgery for adhesive small-bowel obstruction at a single academic center between January 2010 and December 2012. Patients with a contraindication for the laparoscopic approach were excluded. A propensity score was used to match patients in the laparoscopic and open surgery groups based on their preoperative parameters.

RESULTS

A total of 25 patients underwent laparoscopic adhesiolysis and 67 patients open adhesiolysis. The open adhesiolysis group had more suspected bowel strangulations and more previous abdominal surgeries than the laparoscopic adhesiolysis group. Severe complication rate (Clavien-Dindo 3 or higher) was 0% in the laparoscopic adhesiolysis group versus 14% in the open adhesiolysis group ( p = 0.052). Twenty-five propensity score-matched patients from the open adhesiolysis group were similar to laparoscopic adhesiolysis group patients with regard to their preoperative parameters. Length of hospital stay was shorter in the laparoscopic adhesiolysis group compared to the propensity score-matched open adhesiolysis group (6.0 vs 10.0 days, p = 0.037), but no differences were found in severe complications between the laparoscopic adhesiolysis and propensity score-matched open adhesiolysis groups (0% vs 4%, p = 0.31).

CONCLUSION

Patients selected to be operated by the open approach had higher preoperative morbidity than the ones selected for the laparoscopic approach. After matching for this disparity, the laparoscopic approach was associated with a shorter length of hospital stay without differences in complications. The laparoscopic approach may be a preferable approach in selected patients.

Cost analysis of robotic versus laparoscopic general surgery procedures

BACKGROUND

Robotic surgical systems have been used at a rapidly increasing rate in general surgery. Many of these procedures have been performed laparoscopically for years. In a surgical encounter, a significant portion of the total costs is associated with consumable supplies. Our hospital system has invested in a software program that can track the costs of consumable surgical supplies. We sought to determine the differences in cost of consumables with elective laparoscopic and robotic procedures for our health care organization.

METHODS

De-identified procedural cost and equipment utilization data were collected from the Surgical Profitability Compass Procedure Cost Manager System (The Advisory Board Company, Washington, DC) for our health care system for laparoscopic and robotic cholecystectomy, fundoplication, and inguinal hernia between the years 2013 and 2015. Outcomes were length of stay, case duration, and supply cost. Statistical analysis was performed using a t-test for continuous variables, and statistical significance was defined as p < 0.05.

RESULTS

The total cost of consumable surgical supplies was significantly greater for all robotic procedures. Length of stay did not differ for fundoplication or cholecystectomy. Length of stay was greater for robotic inguinal hernia repair. Case duration was similar for cholecystectomy (84.3 robotic and 75.5 min laparoscopic, p = 0.08), but significantly longer for robotic fundoplication (197.2 robotic and 162.1 min laparoscopic, p = 0.01) and inguinal hernia repair (124.0 robotic and 84.4 min laparoscopic, p = ≪0.01).

CONCLUSIONS

We found a significantly increased cost of general surgery procedures for our health care system when cases commonly performed laparoscopically are instead performed robotically. Our analysis is limited by the fact that we only included costs associated with consumable surgical supplies. The initial acquisition cost (over $1 million for robotic surgical system), depreciation, and service contract for the robotic and laparoscopic systems were not included in this analysis.