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Ghabisha S, Ahmed F, Altam A, Hassan F, Badheeb M. Small Bowel Obstruction in Virgin Abdomen: Predictors of Surgical Intervention Need in Resource-Limited Setting. J Multidiscip Healthc 2023; 16:4003-4014. [PMID: 38107087 PMCID: PMC10725698 DOI: 10.2147/jmdh.s441958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023] Open
Abstract
Background Limited evidence is available regarding the management of small bowel obstruction in the virgin abdomen (SBO-VA), with most studies excluding this entity. This study aims to assess the available data on the treatment outcomes and predictors of surgical intervention in SBO-VA. Methods A retrospective cross-sectional study was conducted between 2015 and 2021, including all diagnosed and managed cases of SBO-VA at Al-Nasar Hospital. Patients were divided according to the treatment approach into surgical or conservative groups. Preoperative laboratory and radiologic data were gathered and compared between groups. Results During the study period, 67 cases, primarily males (58.2%), with an average age of 52.2±14.4 years were assessed. Common comorbidities included diabetes (20.9%) and hypertension (16.4%). Key symptoms were rebound tenderness (82.1%) and abdominal tenderness (70.1%). The predominant etiology was adhesions (23.9%). About 46.2% received conservative treatment, 53.8% underwent urgent surgery. Conservative treatment failed in 9.4% of cases, and complications arose in 23.9%, with most being fever (17.9%). Factors necessitating surgical management included older age (58.8 ±11.7 vs 44.9 ±13.8 years, p<0.001), previous hospital admission (p<0.001), presence of abdominal tenderness (p=0.030), longer abdominal pain duration (4.0 ±0.9 vs 2.1 ±0.6 days, p<0.001), higher C- reactive protein (p= 0.033), higher white blood cell (p= 0.006), longer time to hospital presentation (75.3 ±17.2 vs 39.0 ±22.8 days, p= <0.001), small bowel thickness ≥3 cm (p=0.009), and reduced bowel enhancement (p <0.001) on computed tomography imaging. In surgical group, the need for ICU admission was higher and hospital stays were shorter than in conservative group and were statistically significant (p<0.05). Conclusion The main etiology of SBO-VA in our study was adhesions. Older age, previous hospital admission, longer abdominal pain duration, abdominal tenderness, increased inflammatory markers, and alarm signs on CT scans are the main factors for determining the need for urgent surgical exploration in patients with SBO-VA. To achieve prompt identification and intervention, it is crucial to maintain a high level of vigilance and awareness, even in individuals with no prior surgical history.
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Affiliation(s)
- Saif Ghabisha
- Department of General Surgery, School of Medicine, Ibb University, Ibb, Yemen
| | - Faisal Ahmed
- Department of Urology, School of Medicine, Ibb University, Ibb, Yemen
| | - Abdulfattah Altam
- Department of General Surgery, School of Medicine, 21 September University, Sana’a, Yemen
| | - Fouad Hassan
- Department of Nutrition and Dietetics, School of Medicine, Ibb University, Ibb, Yemen
| | - Mohamed Badheeb
- Department of Internal Medicine, Yale New-Haven Health/Bridgeport Hospital, Bridgeport, CT, USA
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Abstract
PURPOSE OF REVIEW Intrabdominal adhesions and intestinal hernias are the commonest cause of small bowel obstruction. Small bowel diseases, which cause small bowel obstruction, are rarer and often poses a challenge to gastroenterologists to diagnose and treat. In this review, small bowel diseases, which predispose to small bowel obstruction, are focused on, and their challenges in diagnosis and treatment. RECENT FINDINGS Diagnosis of causes of partial small bowel obstruction is improved with computed tomography (CT) and magnetic resonance (MR) enterography. In fibrostenotic Crohn's strictures and NSAID diaphragm disease, endoscopic balloon dilatation can delay the need for surgery if the lesion is short and accessible; however, many may still inevitably require surgery. Biologic therapy may reduce the need for surgery in symptomatic small bowel Crohn's disease wherein the strictures are predominantly inflammatory. In chronic radiation enteropathy, only refractory small bowel obstruction and those with nutritional difficulties warrant surgery. SUMMARY Small bowel diseases causing bowel obstruction are often challenging to diagnose and require numerous investigations over a period of time, which often culminate with surgery. Use of biologics and endoscopic balloon dilatation can help to delay and prevent surgery in some instances.
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Affiliation(s)
- Foong Way David Tai
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Reena Sidhu
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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Peterson J, Cox C, Unrue E, Steed R, Mentzer C, Currence C, Mount M. Utility of Abbreviated Small Bowel Follow Through Study in the Management of Small Bowel Obstruction. Am Surg 2023:31348231161661. [PMID: 36920989 DOI: 10.1177/00031348231161661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
INTRODUCTION Small bowel obstruction is a common surgical complaint. Most small bowel obstructions are managed successfully nonoperatively. Unanimous guidelines for nonoperative management of small bowel obstruction do not exist. METHODS A standardized protocol for water-soluble contrast administration and abbreviated small bowel follow through imaging was implemented in January of 2021. A retrospective chart review identified 111 patients admitted for SBO from 6/2019 to 9/2019 for a control group. A planned follow-up review identified 158 patients managed according to the new protocol from 3/2021 to 10/2021. The primary outcome was in-hospital length of stay. Standard statistical analyses were performed and pre-specified. RESULTS Before implementation of the standardized protocol patients that were managed strictly nonoperatively, the mean length of stay (LOS) was 8.3 days. After implementation, the average LOS was 4.8 (P < .0001). Comparatively, patients admitted after protocol implementation were more likely to undergo CT scan with PO contrast on admission (98.1% vs 90.1%; P < .005), undergo NG tube decompression (84.7% vs 68.5%; P < .005), and undergo water-soluble contrast with abbreviated or formal SBFT (75.3% vs 37.8%; P < .0001). CONCLUSION Implementation of a standardized protocol utilizing abbreviated SBFT with water-soluble contrast for the management of SBO at our institution resulted in a decrease in the average length of stay for patients definitively managed in a nonoperative fashion.
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Affiliation(s)
- John Peterson
- Department of Surgery, 7442Spartanburg Regional Healthcare System, Spartanburg, USA
| | - Caroline Cox
- Department of Surgery, 7442Spartanburg Regional Healthcare System, Spartanburg, USA
| | - Emily Unrue
- 447877Edward Via College of Osteopathic Medicine - Carolinas Campus, Spartanburg, USA
| | - R Steed
- Department of Surgery, 7442Spartanburg Regional Healthcare System, Spartanburg, USA
| | - Caleb Mentzer
- Department of Surgery, 7442Spartanburg Regional Healthcare System, Spartanburg, USA
| | - Cragin Currence
- Department of Surgery, 7442Spartanburg Regional Healthcare System, Spartanburg, USA
| | - Michael Mount
- Department of Surgery, 7442Spartanburg Regional Healthcare System, Spartanburg, USA
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Lewis M, Liasidis PK, Huang VP, Benjamin ER, Ghafil C, Jakob DA, Demetriades D. Small Bowel Obstruction in the Virgin Abdomen. J Gastrointest Surg 2023; 27:411-412. [PMID: 35970952 DOI: 10.1007/s11605-022-05294-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 03/02/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Meghan Lewis
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA.
| | - Panagiotis K Liasidis
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
| | - Valerie P Huang
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
| | - Elizabeth R Benjamin
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
| | - Cameron Ghafil
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
| | - Dominik A Jakob
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
| | - Demetrios Demetriades
- Division of Acute Care Surgery, Department of Surgery, California Medical Center, Los Angeles County and University of SouthernUniversity of Southern CaliforniaIPT, 2051 Marengo Street, Los Angeles, CA, C5L 10090033, USA
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Jang Y, Jung SM, Heo TG, Choi PW, Kim JI, Jung SW, Jun H, Shin YC, Um E. Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study. Ann Coloproctol 2022; 38:423-431. [PMID: 34875819 PMCID: PMC9816557 DOI: 10.3393/ac.2021.00710.0101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/23/2021] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Most of the causes of small bowel obstruction (SBO) in patients without a history of abdominal surgery are unclear at initial assessment. This study was conducted to identify the etiology and clinical characteristics of SBO in virgin abdomens and discuss the proper management. METHODS A retrospective review involving operative cases of SBO from a single institute, which had no history of abdominal surgery, was conducted between January 2010 and December 2020. Clinical information, including radiological, operative, and pathologic findings, was investigated to determine the etiology of SBO. RESULTS A total of 55 patients were included in this study, with a median age of 57 years and male sex (63.6%) constituting the majority. The most frequently reported symptoms were abdominal pain and nausea or vomiting. Neoplasm as an underlying cause accounted for 34.5% of the cases, of which 25.5% were malignant cases. In patients aged ≥60 years (n=23), small bowel neoplasms were the underlying cause in 12 (52.2%), of whom 9 (39.1%) were malignant cases. Adhesions and Crohn disease were more frequent in patients aged <60 years. Coherence between preoperative computed tomography scans and intraoperative findings was found in 63.6% of the cases. CONCLUSION There were various causes of surgical cases of SBO in virgin abdomens. In older patients, hidden malignancy should be considered as a possible cause of SBO in a virgin abdomen. Patients with symptoms of recurrent bowel obstruction who have no history of prior abdominal surgery require thorough medical history and close follow-up.
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Affiliation(s)
- Youngjin Jang
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Sung Min Jung
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea,Correspondence to: Sung Min Jung, M.D. Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea Tel: +82-31-911-7993, Fax: +82-31-911-7319 E-mail:
| | - Tae Gil Heo
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Pyong Wha Choi
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Jae Il Kim
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Sung-Won Jung
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Heungman Jun
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Yong Chan Shin
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
| | - Eunhae Um
- Department of Surgery, University of Inje College of Medicine, Ilsan Paik Hospital, Goyang, Korea
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Small Bowel Obstruction in Patients without Prior Abdominal Surgery: To Operate or Not? World J Surg 2022; 46:2919-2926. [PMID: 36059038 DOI: 10.1007/s00268-022-06719-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Surgical exploration is still considered mandatory in the setting of small bowel obstruction (SBO) in patients without prior intra-abdominal surgery. However, recent studies have challenged this 'classic' approach describing success with conservative non-surgical treatment. The aim of this study is to identify clinical, radiological and biochemical variables that may be associated with the absence of intra-abdominal pathology in patients with SBO who have not undergone previous surgery. METHODS This is a retrospective cohort study of prospectively recorded data. Patients with SBO without prior abdominal surgery who presented to a single tertiary referral medical center between 2009 and 2019 were included. RESULTS Eighty-seven patients were included of whom 61(70.0%) were allocated to the 'therapeutic exploration' group and 26 (30.0%) to the 'non-therapeutic exploration' group. Forty-eight patients (55.0%) had adhesions, 17.2% had closed-loop obstruction, 10.0% had an internal hernia, 27.6% had bowel ischemia and 5.7% had bowel necrosis. Although multiple clinical, laboratory, radiological and preoperative factors were examined, none were significantly associated with pathological findings during surgical exploration. There was no statistically significant difference in the incidence of complications when comparing between those groups. CONCLUSIONS In this series, no variables were associated with intra-abdominal pathology in patients who underwent surgery for SBO with no history of prior abdominal surgery. However, the fact that 27.0% had ischemic bowel upon surgical exploration suggests that this approach is still mandatory for this specific group of patients. Furthermore, clinicians and patients should be aware that negative exploration may be expected in up to 30.0%.
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Baker S, Miller-Hammond K, King-Mullins E. Small Bowel Obstruction in the Virgin Abdomen. Surg Clin North Am 2021; 101:1045-1052. [PMID: 34774267 DOI: 10.1016/j.suc.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This article highlights the quagmire of the surgeon who encounters a small bowel obstruction in the absence of previous abdominopelvic surgery. Historic literature implies urgent surgical intervention is required; however, there is no current standard of care to guide management. Key principles of general surgery apply, and definitive management is based on the provider's clinical judgment after synthesizing key clinical history and additional diagnostic imaging studies.
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Affiliation(s)
- Sarah Baker
- Georgia Colon and Rectal Surgical Associates, Northside Hospital, 5445 Meridian Mark Road, Suite 180, Atlanta, GA 30342, USA
| | | | - Erin King-Mullins
- Georgia Colon and Rectal Surgical Associates, Northside Hospital, 5445 Meridian Mark Road, Suite 180, Atlanta, GA 30342, USA.
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8
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Azimi-Ghomi O, Kahane G. Ileal Tubulo-Villous Adenoma Causing Small Bowel Obstruction in a Virgin Abdomen. Cureus 2021; 13:e17421. [PMID: 34589331 PMCID: PMC8460552 DOI: 10.7759/cureus.17421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 12/29/2022] Open
Abstract
Small bowel obstructions (SBO) are a common surgical problem accounting for up half of all emergency laparotomies in the United States. SBO in the virgin abdomen (SBO-VA) presents surgeons with a unique predicament as historical teaching has mandated operative exploration in these situations due to their association with more sinister etiologies. More recent research has demonstrated that this may not be the case, with adhesive disease comprising the majority of SBO-VA. Small bowel neoplasms however comprise a considerable portion of SBO-VA. Small bowel tumors comprise around 0.5%-2% of all gastrointestinal tumors, with adenomas being the most common type of benign small bowel tumor. These lesions are most commonly encountered in the duodenum, typically involving the peri-ampullary region, Their incidence decreases with descent down the gastrointestinal tract, and are least commonly found in the ileum. Ileal adenomas have been increasingly described in the literature with the rise of advanced imaging and endoscopic capabilities. The vast majority of these lesions remain asymptomatic; however, they have been reported to undergo malignant transformation resulting in obstruction and intussusception. Small bowel obstruction due to ileal adenomas in the absence of malignancy is exceedingly rare, with only one previously reported case in the literature. We describe a case of an SBO-VA secondary to ileal stricture caused by a tubulo-villous adenoma. We then discuss the topics of SBO and SBO-VA, specifically regarding their etiology and historical and modern management, with a particular focus on the diagnosis and management of small bowel neoplasms, specifically small bowel adenomas.
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Affiliation(s)
| | - Gerardo Kahane
- General Surgery, Aventura Hospital and Medical Center, Aventura, USA
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9
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Amara Y, Leppaniemi A, Catena F, Ansaloni L, Sugrue M, Fraga GP, Coccolini F, Biffl WL, Peitzman AB, Kluger Y, Sartelli M, Moore EE, Di Saverio S, Darwish E, Endo C, van Goor H, Ten Broek RP. Diagnosis and management of small bowel obstruction in virgin abdomen: a WSES position paper. World J Emerg Surg 2021; 16:36. [PMID: 34217331 PMCID: PMC8254282 DOI: 10.1186/s13017-021-00379-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
Background Small bowel obstruction (SBO) is a common surgical emergency, causing high morbidity and healthcare costs. The majority of SBOs are caused by adhesions that result from previous surgeries. Bowel obstruction, however, also occurs in patients without previous operation or known pathology, a so called virgin abdomen. It is unknown if small bowel obstruction in the virgin abdomen (SBO-VA) can be managed according to the same principles as other cases of small bowel obstruction. The aim of this position paper is to evaluate the available evidence on etiology and management of small bowel obstruction in the virgin abdomen. Methods This is a narrative review with scoping aspects. Clinical topics covered in this review include epidemiology and etiology of SBO-VA, diagnosis and imaging, initial assessment, the role of surgical management in SBO-VA, and the role of non-operative management in SBO-VA. Results Our scoping search revealed seven original studies reporting original patient data related to SBO-VA. All the included studies are retrospective cohorts, with populations ranging between 44 and 103 patients with SBO-VA. Adhesions were found to be the cause of the obstruction in approximately half of the reported cases of SBO-VA. A relatively high number of cases of SBO-VA were managed surgically with studies reporting 39–83%. However, in cases where a trial of non-operative management was started, this was generally successful. Conclusion The data available suggest that etiology and treatment results for patients with SBO-VA are largely comparable to the results in patients with SBO after previous abdominal surgery. We therefore propose that patients with a virgin abdomen could be treated according to existing guidelines for SBO and adhesive small bowel obstruction.
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Affiliation(s)
- Yousef Amara
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of General Surgery, The Baruch Padeh Medical Centre, Poriya, Israel
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Fausto Catena
- Department of General Surgery, Parma University Hospital, Parma, Italy
| | - Luca Ansaloni
- General Emergency And Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM), Unicamp Campinas, São Paulo, Brazil
| | | | - Walter L Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, Hawaii, USA
| | - Andrew B Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus Haifa, Haifa, Israel
| | | | | | | | - Esfo Darwish
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Chikako Endo
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Richard P Ten Broek
- Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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10
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Non-operative Management of Small Bowel Obstruction in Patients with No Previous Abdominal Surgery: A Systematic Review and Meta-analysis. World J Surg 2021; 45:2092-2099. [PMID: 33755752 DOI: 10.1007/s00268-021-06061-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2021] [Indexed: 01/30/2023]
Abstract
While the contemporary management of adhesive small bowel obstruction (SBO) often includes a trial of non-operative management (NOM), surgical dogma dictates urgent operative exploration in patients without previous abdominal surgery. This dogma has been challenged by recent evidence suggesting most obstructions in this population are adhesive in nature. The objectives of this review were to evaluate the feasibility of NOM in patients with SBO and no history of previous abdominal surgery, to examine the etiologies of SBO in this population, and to explore the rate of adverse events seen following NOM. Embase, Medline, Cochrane, and Google Scholar were searched from inception to September 24, 2019. Articles reporting on NOM for SBO in patients without previous abdominal surgery and without clinical or radiographic features necessitating an emergent operation were included. Data were combined to obtain a pooled proportion of patients discharged without operation following a trial of NOM. 6 studies reporting on a total of 272 patients were included. The pooled proportion of patients discharged following NOM was 49.5% (95% CI 23.7-75.3%). Adhesions were found to be the predominant cause of obstruction. NOM did not appear to increase short-term complications. Most SBOs in patients without previous abdominal surgery are adhesive in nature and many patients can be discharged from hospital without surgery. While the short-term outcomes of NOM are acceptable, future studies are needed to address the long-term outcomes and safety of NOM as a treatment strategy for SBO in patients without previous abdominal surgery.
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11
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Non-operative management of small bowel obstruction in virgin abdomen: a systematic review. Surg Today 2021; 51:1558-1567. [PMID: 33481087 DOI: 10.1007/s00595-020-02210-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 10/22/2022]
Abstract
The aim of this study was to systematically review the feasibility and safety of non-operative management of small bowel obstruction (SBO) in virgin abdomen. A systematic review was performed through December 2019. The primary outcome was the resolution of non-operative management of SBO in virgin abdomen. Secondary outcomes were the etiology of SBO and findings of exploratory laparotomy. Six studies were included in the analysis. Of the 442 patients, 2 with metastatic cancer received palliative care, and the management in 26 was not reported, so these patients were excluded. A total of 414 patients were ultimately analyzed, including 203 patients (49%) who were managed non-operatively and 211 (51%) who underwent surgical management. Of the 203 managed non-operatively, the condition of 194 (96%) was resolved without further intervention. The remaining 9 (5%) patients failed non-operative management and ultimately required surgery. Of the 211 patients who underwent surgical exploration, only 137 had their intraoperative findings reported. Adhesions (n = 67; 49%) were the main cause, followed by malignancy (n = 14; 10%) and others (n = 33; 24%). No cause was found in 23 patients (17%). In highly select cases of SBO with virgin abdomen, non-operative management can be attempted if patients are clinically stable and computed tomography does not demonstrate concerning features or obvious pathology. Further well-designed prospective studies will be required prior to the introduction of this concept in clinical practice, as current evidence remains heterogeneous.
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12
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Figueiredo SMPD, Demola S. Successful use of water-soluble contrast in patients with small bowel obstruction and virgin abdomen: A case report. Int J Surg Case Rep 2021; 79:94-96. [PMID: 33453466 PMCID: PMC7811061 DOI: 10.1016/j.ijscr.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/02/2021] [Accepted: 01/02/2021] [Indexed: 11/25/2022] Open
Abstract
Trial of nonoperative management is standard of care for adhesive SBO. Prior surgery is the most common cause of adhesions. Management of SBO in patients without prior surgery is a challenge. This is a case of SBO in a virgin abdomen patient successfully managed nonoperatively.
Introduction and importance Nonoperative management of adhesive SBO is well established but remains a challenge in patients without prior abdominal surgery. We aim to report a case of successful nonoperative management with the use of enteral hypertonic water-soluble contrast administration in a patient with virgin abdomen. Case presentation A healthy 24-year old man with no previous surgery presented to the emergency room with one day of abdominal pain. A CT abdomen and pelvis was consistent with SBO without clear anatomic etiology. The patient refused surgical intervention, so we performed a trial of nonoperative management. On hospital day 2, a repeat CT A/P with enterally administered water-soluble contrast showed resolution of SBO. The patient has had no symptoms since hospital discharge on 6 months follow up. Clinical discussion Small bowel obstruction is most commonly secondary to adhesions from prior surgeries. Even in patients with virgin abdomen, adhesions are the cause of SBO in 53%–73%. Recent studies in patients with virgin abdomen showed that 92.1% that underwent nonoperative management did not have a recurrence of SBO with mean follow up of 4.5 years. The use of water-soluble contrast in patients with virgin abdomen was reported to have 92–97% success rate. A meta-analysis showed a pooled prevalence of 7.7% of malignant etiology of SBO in these patients, more common with previous SBO admission or history of malignancy. Conclusion Nonoperative management with the therapeutic use of hypertonic water-soluble contrast is a viable treatment option in select cases and avoids the morbidity of surgical exploration.
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Affiliation(s)
| | - Sara Demola
- Department of Surgery, University of Texas Medical Branch Hospital, 301 University Blvd, Galveston, TX 77555, United States
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13
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Yang TWW, Prabhakaran S, Bell S, Chin M, Carne P, Warrier SK, Skinner S, Kong JC. Non-operative management for small bowel obstruction in a virgin abdomen: a systematic review. ANZ J Surg 2020; 91:802-809. [PMID: 33084181 DOI: 10.1111/ans.16392] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Small bowel obstruction (SBO) is a common general surgical presentation and there has been a shift towards non-operative management (NOM) for patients with previous abdominal surgery. Historically, exploratory surgery has been mandated for SBO in patients with a virgin abdomen. However, there is increasing evidence for NOM in this group of patients. METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search was undertaken between 1995 and 2020 on Ovid MEDLINE, EMBASE and PubMed. Primary outcome measures were success and failure rates, whereas secondary outcome measures were morbidity, mortality rates and identifying underlying aetiologies. RESULTS Six observational studies were included, with 205 patients in the NOM and 211 patients in the operative group. There was a high success rate of 95.6% and low morbidity rate of 3.1% in the NOM group compared to 88.6% and 26% in the operative group, respectively. Both groups reported no mortalities. The most common aetiologies for SBO in a virgin abdomen were adhesions (63%), malignancy (11%), foreign body/bezoar (5%), internal hernia (4%) and volvulus (4%). CONCLUSION NOM for SBO is a safe and feasible option for a select group of clinically stable patients with a virgin abdomen without features of closed-loop obstruction. Adhesions are the most common cause of SBO in this group of patients. Further large-scale prospective clinical studies with standardized NOM modality, homogenous clinical resolution indicators and long-term follow-up data are warranted to allow for quantitative analysis to reinforce this evidence.
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Affiliation(s)
- Tze W W Yang
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Swetha Prabhakaran
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephen Bell
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Martin Chin
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter Carne
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Stewart Skinner
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph C Kong
- Department of General Surgery, Colorectal Surgery Unit, Alfred Hospital, Melbourne, Victoria, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
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Safety of Foregoing Operation for Small Bowel Obstruction in the Virgin Abdomen: Systematic Review and Meta-Analysis. J Am Coll Surg 2020; 231:368-375.e1. [DOI: 10.1016/j.jamcollsurg.2020.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 12/29/2022]
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