Bowel obstruction in the aged patient. A review of 300 cases

Reoperation for small bowel obstruction--how critical is the timing?

The timing of reoperation for small bowel obstruction is a topic of significant debate. Any patient with evidence of strangulation should undergo urgent surgical intervention. However, predicting strangulation can be difficult. Because of this, previous authors have recommended everything from emergency operation for all patients presenting with small bowel obstruction to periods of observation that extend up to 14 days. Over the past century, the primary etiology of small bowel obstruction has shifted from hernias to postoperative adhesive disease, leading to a shift in the management paradigm. To manage small bowel obstruction successfully today, the clinician must distinguish the patient requiring urgent operation from those who benefit from nonoperative management. Furthermore, the clinician must be able to determine the appropriate length of time for conservative management. In this article we review the significant body of literature on this topic including the diagnostic workup and timing of potential operative intervention in the patient with small bowel obstruction.

Early outcomes of surgery for small bowel obstruction: analysis of risk factors

OBJECTIVES

The study aimed to review the etiologies of patients who underwent surgery for small bowel obstruction (SBO) and to evaluate the risk factors affecting the early postoperative outcomes.

MATERIALS AND METHODS

A case series of 430 patients (252 men) with a mean age of 64.5 years, who underwent 437 operations for SBO, were retrospectively reviewed.

RESULTS

Peritoneal adhesions and hernia were the most common causes of SBO, contributing 42.3 and 26.8% of all cases, respectively. Strangulation occurred in 27.7% and caused nonviable bowel in 13.0% of obstructing episodes. Old age (age >/= 70 years), female patient, nonadhesive obstruction, and hernia were the independent significant factors associated with bowel strangulation. The 30-day mortality was 6.5%, and the median postoperative hospital stay was 8 days. Old age, the presence of premorbid pulmonary disease, and malignant obstruction were the independent factors associated with operative mortality. The overall complication rate was 35.5%, and old age was the only significant factor associated with postoperative complications.

CONCLUSIONS

Surgery for SBO is still associated with significant mortality and morbidity. As old age is significantly associated with an increased incidence of strangulation, operative mortality, and complications, this group of patients should be managed with extra cautions to avoid unfavorable outcome of surgery.

Acute abdominal pain

Acute abdominal pain is a complaint seen commonly in the outpatient setting that has a broad and often confusing differential diagnosis. Although many presentations can be managed on an outpatient basis, several gastrointestinal causes of abdominal pain demand thoughtful consideration with subsequent referral to a higher level of care for appropriate diagnosis and treatment. To achieve this goal, outpatient physicians must have an understanding of the mechanisms of abdominal pain, as well as the common gastrointestinal causes that carry potentially higher morbidity and mortality.

Acute abdominal pain

Because there are many causes of acute abdominal pain, a systematic approach by the evaluating physician is necessary to narrow the differential diagnosis. It is vital that the physician have an understanding of the mechanisms of pain generation and be familiar with the presentations of common diseases that cause abdominal pain. Recognizing the red flags in the history and physical examination and the initial imaging and laboratory findings helps to determine which patients may have a serious underlying disease process, and therefore warrant more expedited evaluation and treatment.

Bowel obstruction and pseudo-obstruction

The gastroenterologist is frequently involved in the care of patients with bowel obstruction and pseudo-obstruction. In the case of obstruction, the central problem is determining which patients should be managed surgically. In both SBO and LBO, evidence of vascular compromise to the gut mandates surgical intervention. Most patients with pseudo-obstruction respond to conservative therapy or neostigmine. Endoscopic decompression is indicated in recalcitrant cases, with surgery reserved as a last resort.

Etiology of small bowel obstruction

BACKGROUND

Small bowel obstruction (SBO) is a major cause of morbidity and financial expenditure in hospitals around the world. The leading cause of SBO in the western world has become adhesions. The goal of this study was to determine the causes of SBO.

METHODS

The medical records of all patients admitted to one hospital between 1986 and 1996 with the diagnosis of SBO were reviewed retrospectively. This included 552 patients accounting for 1,001 admissions.

RESULTS

The etiology of SBO was adhesions (74%), Crohn's disease (7%), neoplasia (5%), hernia (2%), radiation (1%), and miscellaneous (11%). Patients with Crohn's disease were younger than patients with other etiologies. Surprisingly, recurrence rates were similar for patients treated operatively as for those treated nonoperatively with the exception in the hernia group where higher recurrence rates were noted for patients initially treated in a nonoperative manner.

CONCLUSION

The most common cause of SBO is adhesions followed by Crohn's disease and neoplasia.

Complications and death after surgical treatment of small bowel obstruction: A 35-year institutional experience

OBJECTIVE

To study factors influencing complications and death after operations for small bowel obstruction (SBO) using multifactorial statistical methods.

SUMMARY BACKGROUND DATA

Death after surgery for SBO is believed to be influenced by factors such as old age, comorbidities, bowel gangrene, and delay in treatment. No studies have been reported in which adverse factors related to death and complications have been systematically investigated with modern statistical methods.

METHODS

The authors studied retrospectively 877 patients who underwent 1,007 operations for SBO from 1961 to 1995. Patients with paralytic ileus, intussusception, and abdominal cancer were excluded. Odds ratios for death, complications, postoperative hospital stay, and strangulation were calculated by means of logistic regression analyses.

RESULTS

Death and complication rates decreased during the study period. Old age, comorbidity, nonviable strangulation, and a treatment delay of more than 24 hours were significantly associated with an increased death rate. The rate of nonviable strangulation increased markedly with patient age. Major factors increasing the complication rate were old age, comorbidity, a treatment delay of more than 24 hours, and the need for repeat surgery.

CONCLUSION

Death and complication rates after SBO decreased from 1961 to 1995. Major factors influencing the rates were age, comorbidity, nonviable strangulation, and treatment delay. Nonviable strangulation was more common in old patients.

Small intestinal obstruction

Small intestinal obstruction remains a frequently encountered problem in abdominal surgery. Although modern day surgical management continues to focus appropriately on avoiding operative delay whenever surgery is indicated, not every patient is always best served by immediate operation. Certain entities, such as SBO secondary to incarcerated abdominal wall hernia, and patients with clinical signs and symptoms suggestive of strangulation do require prompt operative intervention. Other conditions, however, such as postoperative adhesions and neoplastic-associated SBO, particularly in patients with numerous previous abdominal procedures, concomitant medical problems, or incomplete or partial obstruction, often justifiably benefit by a trial of nonoperative management. The risk of strangulation with adhesive and neoplastic SBO is relatively low as compared with incarcerated hernia and small bowel volvulus. Close and careful clinical evaluation, in conjunction with laboratory and radiologic studies, will usually dictate the proper course of management in any given case. If any uncertainty exists, prompt operative intervention is indicated. Because over 50 per cent of all cases of SBO are the direct result of postoperative adhesions, it is probably just as important as the actual management of SBO for all practicing abdominal surgeon to familiarize themselves with the widely accepted "ischemic theory" of adhesion formation. A number of intraoperative measures, many of which go against established surgical principles, are now encouraged during routine elective abdominal surgery to reduce the incidence of detrimental adhesions that might subsequently produce SBO. At the same time, surgeons should continue their aggressive attitude towards elective repair of any and all abdominal hernias, which continue to account for close to 15 per cent of all cases of small intestinal obstruction and still remain the most common cause of strangulation.

Colorectal cancer in patients older than 75 years of age

Two hundred and seven hospital records of patients with colon or rectal cancer from 1982 to 1985 were reviewed retrospectively. Ninety-six patients were 75 years of age or older and 111 were younger than 75 years. Comparison of the two groups showed that the elderly group presented with lower hematocrits and serum albumin values despite comparable pathologic stages and tumor location. A higher preanesthetic stage was seen in the elderly group. The total perioperative mortality rates for the young and elderly groups were 3.6 percent and 7.1 percent, respectively, and were not statistically different. Emergency perioperative mortality rates were 5.2 percent and 10 percent, respectively, and also were not statistically different. All nine patients aged 90 and older underwent a major abdominal operation without the occurrence of any perioperative mortality. This study suggests that age need no longer be considered a major risk factor for immediate surgical outcome in colorectal cancer.

[Gallstone ileus--a diagnostic and indications problem--report on 35 patients]

The clinical data of 35 patients with gallstone ileus treated between 1970 and 1984 at the Department of Surgery of the University Hospital of Freiburg were retrospectively analysed with respect to duration of symptoms prior to surgery, preoperative diagnostic, operative procedure and outcome. No reliable test could be found that will lead the clinician to the correct diagnosis in most cases. The classical sign of gallstone ileus--small bowel obstruction combined with pneumobilia in the plain abdominal X-ray--was apparent only in 20%. So, a high index of suspicion, especially in old female patients with small bowel obstruction and prompt surgical intervention will decrease mortality. Enterotomy with removal of the stone without simultaneous cholecystectomy can be recommended as a safe procedure even in very old patients.

Gallstone ileus: a diagnostic problem

A retrospective review of 24 patients with gallstone ileus from our institutions during the period from 1947 through 1981 has been presented. The study was undertaken in an attempt to refine the diagnosis and treatment of this rare entity. The patients ranged in age from 58 to 84 years, and 19 patients were women. The correct preoperative diagnosis was made in 74 percent of the patients using various combinations of clinical history, plain film roentgenograms, and barium contrast upper gastrointestinal series. After an average preoperative hospital stay of 4.5 days, 23 patients required operation. Wound infection developed in nine patients and resulted in wound dehiscence in two. There were four deaths in the patients over 73 years of age (p less than 0.01). Age was the only factor found to correlate with mortality.

Primary malignant tumors of the small intestine. A twenty-two year experience with thirty patients

A review of thirty cases of primary malignant small bowel tumors is presented. Chronic obstruction was the presenting symptom most frequently encountered, with an acute abdomen from perforation of the tumor next in frequency. Adenocarcinoma and carcinoid were about equally encountered, and more than half of all tumors were found in the ileum. Three patients are alive and well, two are alive on chemotherapy, and all others are dead. Five of these died of other causes. Of twenty-seven patients explored for symptomatic small bowel cancers, only one is alive free of tumor. Malignant small bowel tumors are difficult to diagnose early and have a poor prognosis.