Randomised clinical trial investigating the effects of combined administration of octreotide and methylglucamine diatrizoate in the older persons with adhesive small bowel obstruction

Symptom burden and lived experiences of patients, caregivers and healthcare professionals on the management of malignant bowel obstruction: A qualitative systematic review

BACKGROUND

Malignant bowel obstruction occurs in up to 50% of people with advanced ovarian and 15% of people with gastrointestinal cancers. Evaluation and comparison of interventions to manage symptoms are hampered by inconsistent evaluations of efficacy and lack of agreed core outcomes. The patient perspective is rarely incorporated.

AIM

To synthesise the qualitative data regarding patient, caregiver and healthcare professionals' views and experience of malignant bowel obstruction to inform the development of a core outcome set for the evaluation of malignant bowel obstruction.

DESIGN

A qualitative systematic review was conducted, with narrative synthesis. The review protocol was registered prospectively (https://www.crd.york.ac.uk/prospero, CRD42020176393).

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO and Scopus databases were searched for studies published between 2010 and 2021. Reference lists were screened for further relevant publications, and citation tracking was performed.

RESULTS

Nine papers were included, reporting on seven studies which described the views and experiences of malignant bowel obstruction through the perspectives of 75 patients, 13 caregivers and 62 healthcare professionals. Themes across the papers included symptom burden, diverse experiences of interventions, impact on patient quality of life, implications and trajectory of malignant bowel obstruction, mixed experience of communication and the importance of realistic goals of care.

CONCLUSION

Some of the most devastating sequelae of malignant bowel obstruction, such as pain and psychological distress, are not included routinely in its clinical or research evaluation. These data will contribute to a wider body of work to ensure the patient and caregiver perspective is recognised in the development of a core outcome set.

Attitudes Affecting Decision-making for Use of Radiologic Enteral Contrast in the Management of Pediatric Adhesive Small Bowel Obstruction: A Survey Study of Pediatric Surgeons

BACKGROUND

Pediatric surgeons are often asked to treat clinical problems for which little high-quality data exist. For adults with adhesive small bowel obstruction (ASBO), water soluble contrast-based protocols are used to guide management. Little is known about their utility in children. We aimed to better understand key factors in clinical decision-making processes and integration of adult based data in pediatric surgeon's approach to ASBO.

METHODS

We administered a web-based survey to practicing pediatric surgeons at institutions comprising the Western Pediatric Surgery Research Consortium.

RESULTS

The response rate was 69% (78/113). Over half of respondents reported using contrast protocols to guide ASBO management either routinely or occasionally (n = 47, 60%). Common themes regarding the incorporation of adult-based data into clinical practice included the need to adapt protocols for pediatric patients, the dearth of pediatric specific data, and the quality of the published adult evidence.

CONCLUSIONS

Our findings demonstrate that pediatric surgeons use contrast-based protocols for the management of ASBO despite the paucity of pediatric specific data. Furthermore, our survey data help us understand how pediatric surgeons incorporate adult based evidence into their practice.

Development of a core outcome set to use in the research and assessment of malignant bowel obstruction: protocol for the RAMBO study

INTRODUCTION

Studies regarding the management of malignant bowel obstruction (MBO) report conflicting findings. This is partly due to different outcome measures being used to evaluate severity of MBO and the response to treatments. Furthermore, current outcome measures focus mainly on measurable physiological parameters which may not correlate strongly with patient-defined quality of life. The development of core outcome sets allows a consistent approach to evaluating clinical conditions taking into consideration patient, healthcare professional and researcher viewpoints. It follows an internationally recognised standard methodology. We present a protocol for the development of a core outcome set for Research and Assessment of MBO (RAMBO).

METHODS

RAMBO is a multicentre study, comprising of four phases: a systematic review to examine current scope of outcome measures associated with MBO (phase I). Interviews with patients, companions and healthcare professionals will explore priorities and preferences for care and outcomes (phase II). An expert panel meeting will collate the findings into a set of outcomes (phase III), refined by consensus through a Delphi survey with key stakeholders (phase IV). The final set of outcomes will be ratified at a consensus meeting. Each step will actively include patient partners. Thematic analysis and descriptive statistics will be used to analyse qualitative and quantitative data, respectively.

ETHICS AND DISSEMINATION

Ethical approval was obtained (Wales REC 5, REF: 19/LO/1876). Study participants and relevant stakeholders will be updated with newsletters and a lay summary at the end of the study. Abstracts will be submitted to national and international conferences, result papers will be submitted to peer-reviewed, open access journals.

TRIAL AND PROSPERO REGISTRATION NUMBERS

Core Outcome Measures in Effectiveness Trials (1402); Systematic Literature Review (CRD42019150648); Rapid Review (CRD42020176393).

Gastrografin reduces the need for additional surgery in postoperative small bowel obstruction patients without long tube insertion: A meta-analysis

BACKGROUND

Small bowel obstruction (SBO) is a well-known major postoperative complication requiring immediate diagnosis and treatment to avoid additional invasive surgical procedures. Water-soluble contrast medium is often given not only for diagnosis but also for treatment. Although numerous studies have investigated the significance of this treatment, no consensus has yet been established regarding its indications and efficacy.

OBJECTIVE

To explore whether Gastrografin can reduce the need for additional surgery in patients with postoperative SBO (PSBO).

METHODS

We carried out a comprehensive electronic search of the literature (Cochrane Library, MEDLINE, PubMed and the Web of Science) up to February 2017 to identify studies that had shown efficacy of Gastrografin in reducing the need for surgery in patients with PSBO. To integrate the individual effects of Gastrografin, a meta-analysis was done using random-effects models to calculate the risk ratio (RR) and 95% confidence interval (CI), and heterogeneity was analyzed using I 2 statistics.

RESULTS

Twelve studies involving a total of 1153 patients diagnosed as having PSBO were included in this meta-analysis. Not all patients received long-tube insertion. Among 580 patients who received Gastrografin, 100 (17.2%) underwent surgery, whereas among 573 patients who did not receive Gastrografin, 143 (25.0%) underwent surgery. Giving Gastrografin significantly reduced the need for surgery (RR, 0.66; 95% CI, 0.46-0.95; P = 0.02; I 2 = 52%) in comparison with patients who did not receive Gastrografin.

CONCLUSION

Results of this meta-analysis show that giving Gastrografin reduces the need for surgery in PSBO patients without long-tube insertion.

Small bowel obstruction in the elderly: a plea for comprehensive acute geriatric care

Small bowel obstruction is one of the most frequent emergencies in general surgery, commonly affecting elderly patients. Morbidity and mortality from small bowel obstruction in elderly is high. Significant progress has been made in the diagnosis and management of bowel obstruction in recent years. But little is known whether this progress has benefitted outcomes in elderly patients, particularly those who are frail or have a malignancy as cause of the obstruction, and when considering quality of life and functioning as outcomes. In this review, we discuss the specific challenges and needs of elderly in diagnosis and treatment of small bowel obstruction. We address quality of life aspects and explore how the concept of geriatric assessment can be utilized to improve decision-making and outcomes for elderly patients with a small bowel obstruction.

Current management of adhesive small bowel obstruction

Small bowel obstruction is a common and significant surgical presentation. Approximately 30% of presentations will require surgery during admission. The great challenge of adhesive small bowel obstruction (ASBO) management is the early detection of silent intestinal ischaemia in patients initially deemed suitable for conservative therapy. Recent literature emphasizes the effectiveness of computed tomography enterography and water-soluble contrast studies in the management of ASBO. Low-volume undiluted water-soluble contrast has been shown to have both triage and therapeutic value in the management of ASBO. Their use has been demonstrated to reduce the need for surgery to below 20%. There has also been growing interest in clinicoradiological algorithms which aim to predict ischaemia early in the course of presentation. The aim of this review is to summarize the latest evidence and clarify previous uncertainties, specifically regarding the duration of conservative treatment, timing of contrast studies and the reliability of predictive algorithms. Based on this latest evidence, we have formulated a management protocol which aims to integrate these latest developments and formalize a strategy for best management in ASBO.

Somatostatin Analogues Compared With Placebo and Other Pharmacologic Agents in the Management of Symptoms of Inoperable Malignant Bowel Obstruction: A Systematic Review

CONTEXT

Somatostatin analogues are commonly used to relieve symptoms in malignant bowel obstruction (MBO) but are more expensive than other antisecretory agents.

OBJECTIVES

To evaluate the evidence of effectiveness of somatostatin analogues compared with placebo and/or other pharmacologic agents in relieving vomiting in patients with inoperable MBO.

METHODS

MEDLINE, EMBASE, CINAHL, and The Cochrane Controlled Trials Register databases were systematically searched; reference lists of relevant articles were hand searched. Cochrane risk of bias tool was used.

RESULTS

The search identified 420 unique studies. Seven randomized controlled trials (RCTs) met the inclusion criteria (six octreotide studies and one lanreotide); 220 people administered somatostatin analogues and 207 placebo or hyoscine butylbromide. Three RCTs compared a somatostatin analogue with placebo and four with hyoscine butylbromide. Two adequately powered multicenter RCTs with a low Cochrane risk of bias reported no significant difference between somatostatin analogues and placebo in their primary end points. Four RCTs with a high/unclear Cochrane risk of bias reported that somatostatin analogues were more effective than hyoscine butylbromide in reducing vomiting.

CONCLUSION

There is low-level evidence of benefit with somatostatin analogues in the symptomatic treatment of MBO. However, high-level evidence from trials with low risk of bias found no benefit of somatostatin analogues for their primary outcome. There is debate regarding the clinically relevant study end point for symptom control in MBO and when it should be measured. The role of somatostatin analogues in this clinical situation requires further adequately powered, well-designed trials with agreed clinically important end points and measures.

Diagnostic Value of Plain and Contrast Radiography, and Multi-slice Computed Tomography in Diagnosing Intestinal Obstruction in Different Locations

Early intestinal obstruction is easily misdiagnosed. Many physicians consider terminal bouton if computed tomography (CT) scan is done. However, different examinations provide diverse information and significance. This retrospective, randomized, clinical study investigated the diagnostic value of three imaging modalities for intestinal obstruction, supine and upright (or decubitus) plain abdominal radiography, contrast radiography using Gastrografin, and 64 multi-slice spiral CT (MSCT). A total 142 patients with intestinal obstruction were examined. The diagnostic accuracy of plain radiography, contrast radiography, and MSCT for detecting small bowel obstruction was 62.5, 85, and 77.5 %, for localizing the obstruction was 0, 90, and 78.75 %, and for determining the cause of obstruction was 0, 71, and 65 %, respectively. The diagnostic accuracy for detecting large bowel obstruction was 53.23, 73.17, and 92 %, and for localizing the obstruction was 38.17, 60.98, and 98 %, respectively. The diagnostic accuracy of MSCT in determining the cause of obstruction was 91 %. None of the patients administered Gastrografin experienced any adverse effects. In conclusion, MSCT has great diagnostic value in identifying the site and cause of intestinal obstruction, especially in cases of large bowel obstruction. Contrast radiography using Gastrografin was effective in diagnosing and treating small bowel obstruction, making it a beneficial adjunct to MSCT.

Prospective evaluation of oral gastrografin(®) in the management of postoperative adhesive small bowel obstruction

Oral Gastrografin®, a hyperosmolar water-soluble contrast medium, may have a therapeutic effect in adhesive small bowel obstruction. However, findings are still conflicting, as some authors did not find a therapeutic advantage. So, this prospective, randomized, and clinical trial study was designed to determine the value of Gastrografin in adhesive small bowel obstruction. The primary end points were the evaluation of the operative rate reduction and shortening the hospital stay after the use of Gastrografin. A total of 84 patients were randomized into two groups: the control group received conventional treatment, whereas the study group received in addition of 100 mL Gastrografin meal. Patients were followed up within 4 days after admission, and clinical and radiological (if needed) improvements were evaluated. Although the results showed that Gastrografin can decrease the need for surgical management by 14.5 %, no statistically significant differences were observed between the two groups (P = 0.07). Nevertheless, the length of hospital stay revealed a significant reduction from 4.67 ± 1.18 days to 2.69 ± 1.02 days (P = 0.00). The use of Gastrografin in adhesive small bowel obstruction is safe and reduces the length of hospital stay. As a result, the cost of hospital bed occupancy is reduced. Hence, if there was no indication of emergency surgery, administration of oral Gastrografin as a nonoperative treatment in adhesive small bowel obstruction is also recommended.

Efficacy of triple therapy with Sandostatin, Dahuang Fuzi Decoction and XiNeng in the treatment of postoperative acute adhesive intestinal obstruction: an analysis of 45 cases

AIM: To evaluate the efficacy of triple therapy with octreotide acetate (Sandostatin), Dahuang Fuzi Decoction and N(2)-L-alanyl-L-glutamine (XiNeng) in the treatment of postoperative acute adhesive intestinal obstruction.

METHODS: This was a prospective, single-center, randomized controlled clinical trial. Eighty-five patients with postoperative acute adhesive intestinal obstruction who were treated at the Affiliated Zhongshan Hospital of Dalian University from May 2009 to January 2011 were randomly divided into control group (n = 40) and treatment group (n = 45). The control group received conventional treatment, including fasting, gastrointestinal decompression, soapy water enema, rehydration and anti-infection, while the treatment group received triple therapy on the basis of conventional therapy. Both the two groups were treated until the obstruction relieved. Clinical manifestations, the clinical curative effect, the number of cases of conversion to surgery, and the length of hospital stay were compared between the two groups.

RESULTS: Compared to the control group, the treatment group had a shorter time to first anal exhaust (70.7 ± 10.4 h vs 45.3 ± 9.8 h, P < 0.05), time to first defecation (112.4 ± 16.8 h vs 70.5 ± 12.7 h, P < 0.05), stomach tube retention time (135.8 ± 26.7 h vs 91.5 ± 14.1 h, P < 0.05), eating recovery time (158.8 ± 26.4 h vs 109.4 ± 15.7 h, P <0.05), and length of hospital stay (13.9 ± 3.4 d vs 8.2 ± 2.6 d, P < 0.05). In the control group, 19 cases were cured, 13 cases were improved, and 8 cases showed no improvement. In the treatment group, the corresponding figures were 31, 11 and 3, respectively. The total response rate was 93.3% for the treatment group and 80.0% for the control group. The number of cases of conversion to surgery was significantly fewer in the treatment group than in the control group (3 vs 8, P < 0.05).

CONCLUSION: Triple therapy with Sandostatin, Dahuang Fuzi Decoction and XiNeng could significantly improve clinical symptoms, promote the recovery of bowel function, reduce the rate of conversion to surgery, and shorten hospital stay in patients with postoperative acute adhesive intestinal obstruction.

Current management of small bowel obstruction

SBO is a common disease with multiple causes. The most significant advances over the past several years have involved, first, decision-making techniques to promptly and accurately identify patients who will require exploration, and, second, the increasing use of laparoscopic techniques. "Complete" bowel obstruction is becoming an outdated term, as treatment algorithms use predictive models and oral contrast challenges to select patients for operation without recourse to the notion of "complete obstruction." Laparoscopic techniques are gaining acceptance as a primary modality in the treatment of SBO. Appropriate patient selection is necessary for success, but successful laparoscopic SBO management can reduce postoperative pain, minimize hospital stay, and may lead to fewer adhesions, possibly preventing further adhesive SBO. Strangulation obstruction is the major cause of morbidity and mortality in SBO. Although unrecognized strangulation obstructions remain, their incidence is decreasing with the new protocols in development. Future efforts should focus on incorporating predictive models into management with the goal of eliminating unrecognized strangulation obstructions. Further refinement of the predictive models incorporating outcomes of oral contrast challenges and molecular biomarker data may allow surgeons to reach this goal. In addition, the benefit of the elimination of interpractitioner variability conferred by standardized protocols will in itself improve patient outcomes.

Efficacy of octreotide in the management of intestinal obstruction: an analysis of 35 cases

AIM: To evaluate the efficacy of octreotide in the management of intestinal obstruction.

METHODS: Sixty-seven patients with intestinal obstruction diagnosed based on clinical grounds and confirmed by plain abdominal radiography were included in the study. These patients were randomly assigned to two groups: octreotide group (n= 35) and control group (n = 32). There are no significant differences between the two groups in terms of age, sex, time from disease onset to hospitalization, and causes of disease (P > 0.05). Patients of the control group underwent routine therapy, including gastroenterol decompression, injection of vegetable oils through a gastric tube, intravenous replacement of fluid and electrolytes, total parenteral nutrition, and antibiotics. Patients of the octreotide group received routine therapy in combination with subcutaneous administration of octreotide 0.1 mg/8 h for 3-14 d.

RESULTS: After treatment, there is no significant difference in the cure rate between the two groups (P > 0.05). The remission rate of symptoms was significantly higher in the octreotide group than in the control group (85.7% vs 62.5%, P = 0.029). The average amount of nasogastric drainage was significantly lower in the octreotide group than in the control group (355.50 mL/d ± 289.89 mL/d vs 595.63 mL/d ± 287.22 mL/d, P = 0.014). Before treatment, 20 patients in the octreotide group and 16 in the control group had a gastric tube placed. After 72 h of treatment, 16 patients in the octreotide group and 4 in the control group had the gastric tube removed (P < 0.05). The average time required to achieve abdominal pain relief, abdominal distention relief and first postoperative passage of gas was significantly lower in the octreotide group than in the control group (3.27 d ± 1.60 d vs 4.55 d ± 1.76 d, 3.00 d ± 1.55 d vs 4.45 d ± 1.96 d, 2.37 d ± 1.47 d vs 3.20 d ± 1.58 d, all P < 0.05). There is no significant difference in the length of average hospital stay between the two groups.

CONCLUSION: Administration of octreotide in combination with traditional pharmacological treatment is effective and safe in the management of bowel obstruction.

Small bowel obstruction-who needs an operation? A multivariate prediction model

BACKGROUND

Proper management of small bowel obstruction (SBO) requires a methodology to prevent nontherapeutic laparotomy while minimizing the chance of overlooking strangulation obstruction causing intestinal ischemia. Our aim was to identify preoperative risk factors associated with strangulating SBO and to develop a model to predict the need for operative intervention in the presence of an SBO. Our hypothesis was that free intraperitoneal fluid on computed tomography (CT) is associated with the presence of bowel ischemia and need for exploration.

METHODS

We reviewed 100 consecutive patients with SBO, all of whom had undergone CT that was reviewed by a radiologist blinded to outcome. The need for operative management was confirmed retrospectively by four surgeons based on operative findings and the patient's clinical course.

RESULTS

Patients were divided into two groups: group 1, who required operative management on retrospective review, and group 2 who did not. Four patients who were treated nonoperatively had ischemia or died of malignant SBO and were then included in group 1; two patients who had a nontherapeutic exploration were included in group 2. On univariate analysis, the need for exploration (n = 48) was associated (p < 0.05) with a history of malignancy (29% vs. 12%), vomiting (85% vs. 63%), and CT findings of either free intraperitoneal fluid (67% vs. 31%), mesenteric edema (67% vs. 37%), mesenteric vascular engorgement (85% vs. 67%), small bowel wall thickening (44% vs. 25%) or absence of the "small bowel feces sign" (so-called fecalization) (10% vs. 29%). Ischemia (n = 11) was associated (p < 0.05 each) with peritonitis (36% vs. 1%), free intraperitoneal fluid (82% vs. 44%), serum lactate concentration (2.7 +/- 1.6 vs. 1.3 +/- 0.6 mmol/l), mesenteric edema (91% vs. 46%), closed loop obstruction (27% vs. 2%), pneumatosis intestinalis (18% vs. 0%), and portal venous gas (18% vs. 0%). On multivariate analysis, free intraperitoneal fluid [odds ratio (OR) 3.80, 95% confidence interval (CI) 1.5-9.9], mesenteric edema (OR 3.59, 95% CI 1.3-9.6), lack of the "small bowel feces sign" (OR 0.19, 95% CI 0.05-0.68), and a history of vomiting (OR 4.67, 95% CI 1.5-14.4) were independent predictors of the need for operative exploration (p < 0.05 each). The combination of vomiting, no "small bowel feces sign," free intraperitoneal fluid, and mesenteric edema had a sensitivity of 96%, and a positive predictive value of 90% (OR 16.4, 95% CI 3.6-75.4) for requiring exploration.

CONCLUSION

Clinical, laboratory, and radiographic factors should all be considered when making a decision about treatment of SBO. The four clinical features-intraperitoneal free fluid, mesenteric edema, lack of the "small bowel feces sign," history of vomiting-are predictive of requiring operative intervention during the patient's hospital stay and should be factored strongly into the decision-making algorithm for operative versus nonoperative treatment.