Advanced abdominal imaging is not required to exclude strangulation if complete small bowel obstructions undergo prompt laparotomy

Small bowel obstruction after laparoscopic gastrectomy: An atypical clinical presentation. Report of a case

INTRODUCTION

Postoperative adhesions represent the most common cause of acute small bowel obstruction (80%) and are usually a consequence of abdomino-pelvic surgery performed with open technique.

PRESENTATION OF CASE

A 45-year-old black man arrived at the emergency room with abdominal pain and distension three months after laparoscopic distal gastrectomy with Roux-en-Y anastomosis performed for benign pyloric stenosis. CT abdominal scan revealed some air-fluid levels in the center of the abdomen with distension of proximal jejunal loops caused by intestinal adhesions. Laparoscopic adhesiolysis was performed to restore the intestinal transit.

DISCUSSION

The formation of adhesions is more frequent after abdomino-pelvic surgery. CT abdominal scan is very useful tool to identify the level and the aetiology of obstruction and it may predict the need for surgery, the location of different adhesive bands in order to identify wich patients are likely candidates for laparoscopic treatment.

CONCLUSION

In selected cases, laparoscopic approach for small bowel obstruction is a good surgical option. In patients with adbominal dense adhesions or clinical signs of intestinal ischemia, conversion to laparotomy should be considered an alternative.

Assessment of the Clinical Usefulness of Preoperative Computed Tomography in Colorectal Cancer Patients Who Received Unplanned Reoperation

Background

In the unplanned reoperation of colorectal cancer patients, computed tomography (CT) is increasingly utilized to locate postoperative complications and previously unlocalized lesions. The purpose of this study is to explore the application of CT in the mortality and complications of the reoperation of colorectal cancer. Patients and Methods. We performed a retrospective review of collected data from the colorectal surgeries of 90 identified colorectal cancer patients who received an unplanned reoperation from 2010 to 2018. Patients were stratified according to those with preoperative CT imaging (CT group, n = 36) and those without preoperative CT imaging (NCT group, n = 54). Twenty-four statistical indicators of each patient were studied, including their preoperative risk, surgical characteristics, and postoperative outcomes, and satisfaction was evaluated. All data were statistically analysed for predicting postoperative complications by univariate and multivariate logistic regression analyses.

Results

Ninety patients received an unplanned reoperation in the study, and 40% (36/90) of these patients underwent preoperative CT examination. Patients' risk factors were similar between CT and NCT groups. Preoperative imaging was more commonly performed for reoperative new anastomosis + ileostomy but less common for reoperative Dixon's procedure. The operative duration of the NCT group was longer (139 vs. 104 min, respectively, P = 0.01). Preoperative NCT examination (OR 1.24; 95% CI = 1.09-1.42; P = 0.01) was an independent predictor of postoperative complications. Importantly, three patients died after an unplanned reoperation for colorectal cancer, which occurred only in the NCT group (5.6% vs. 0.0%, P = 0.01).

Conclusion

The use of conventional preoperative CT optimizes the choice of the surgical site and the strategy of laparotomy, so as to reduce the length of operation. Preoperative imaging evaluation should be performed for patients undergoing repeat abdominal surgery.

The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review

BACKGROUND

Surgical training has long been to "never let the sun set on a bowel obstruction" without an operation to rule out and/or treat compromised bowel. However, advances in diagnostics have called into question the appropriate timing of non-emergent operations and expectant management is increasingly used. We performed a systematic review to evaluate the safety and effectiveness of expectant management for adhesive small bowel obstruction (aSBO) compared to early, non-emergent operation.

MATERIALS & METHODS

We queried PubMed, EMBASE, and Cochrane databases for studies (1990-present) comparing early, non-emergent operations and expectant management for aSBO (PROSPERO #CRD42017057676).

RESULTS

Of 4873 studies, 29 cohort studies were included for full-text review. Four studies directly compared early surgery with expectant management, but none excluded patients who underwent emergent operations from those having early non-emergent surgery, precluding a direct comparison of the two treatment types of interest. When aggregated, the rate of bowel resection was 29% in patients undergoing early operation vs. 10% in those undergoing expectant management. The rate of successful, non-operative management in the expectant group was 58%. There was a 1.3-day difference in LOS favoring expectant management (LOS 9.7 vs. 8.4 days), and the rate of death was 2% in both groups.

CONCLUSION

Despite the shift towards expectant management of aSBO, no published studies have yet compared early, non-emergent operation and expectant management. A major limitation in evaluating the outcomes of these approaches using existing studies is confounding by indication related to including patients with emergent indications for surgery on admission in the early operative group. A future study, randomizing patients to early non-emergent surgery or expectant management, should inform the comparative safety and value of these approaches.

Emergency Medicine Evaluation and Management of Small Bowel Obstruction: Evidence-Based Recommendations

BACKGROUND

Small bowel obstruction (SBO) is a commonly diagnosed disease in the emergency department (ED). Recent literature has evaluated the ED investigation and management of SBO.

OBJECTIVE

This review evaluates the ED investigation and management of adult SBO based on the current literature.

DISCUSSION

SBO is most commonly due to occlusion of the small intestine, resulting in fluid and gas accumulation. This may progress to mucosal ischemia, necrosis, and perforation. A variety of etiologies are present, but in adults, adhesions are the most common cause. Several classification systems are present. However, the most important distinction is complete vs. partial and complicated vs. simple obstruction, as complete complicated SBO more commonly requires surgical intervention. History and physical examination can vary, but the most reliable findings include prior abdominal surgery, history of constipation, abdominal distension, and abnormal bowel sounds. Signs of strangulation include fever, hypotension, diffuse abdominal pain, peritonitis, and several others. Diagnosis typically requires imaging, and though plain radiographs are often ordered, they cannot exclude the diagnosis. Computed tomography and ultrasound are reliable diagnostic methods. Management includes intravenous fluid resuscitation, analgesia, and determining need for operative vs. nonoperative therapy. Nasogastric tube is useful for patients with significant distension and vomiting by removing contents proximal to the site of obstruction. Surgery is needed for strangulation and those that fail nonoperative therapy. Surgical service evaluation and admission are recommended.

CONCLUSION

SBO is a common reason for admission from the ED. Knowledge of recent literature can optimize diagnosis and management.

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.

Impact of introduction of an acute surgical unit on management and outcomes of small bowel obstruction

BACKGROUND

The acute surgical unit (ASU) is a recently established model of care in Australasia and worldwide. Limited data are available regarding its effect on the management of small bowel obstruction. We compared the management of small bowel obstruction before and after introduction of ASU at a major tertiary referral centre. We hypothesized that introduction of ASU would correlate with improved patient outcomes.

METHODS

A retrospective review of prospectively maintained databases was performed over two separate 2-year periods, before and after the introduction of ASU. Data collected included demographics, co-morbidity status, use of water-soluble contrast agent and computed tomography. Outcome measures included surgical intervention, time to surgery, hospital length of stay, complications, 30-day readmissions, use of total parenteral nutrition, intensive care unit admissions and overall mortality.

RESULTS

Total emergency admissions to the ASU increased from 2640 to 4575 between the two time periods. A total of 481 cases were identified (225 prior and 256 after introduction of ASU). Mortality decreased from 5.8% to 2.0% (P = 0.03), which remained significant after controlling for confounders with multivariate analysis (odds ratio = 0.24, 95% confidence interval 0.08-0.73, P = 0.012). The proportion of surgically managed patients increased (20.9% versus 32.0%, P = 0.003) and more operations were performed within 5 days from presentation (76.6% versus 91.5%, P = 0.02). Fewer patients received water-soluble contrast agent (27.1% versus 18.4%, P = 0.02), but more patients were investigated with a computed tomography (70.7% versus 79.7%, P = 0.02).

CONCLUSION

The ASU model of care resulted in decreased mortality, shorter time to intervention and increased surgical management. Overall complications rate and length of stay did not change.

Adhesive Small Bowel Obstruction: Early Operative versus Observational Management

We assessed the nonoperative and operative management of adhesive small bowel obstruction (ASBO) and compared complication rates and surgical outcomes. ASBO is a common complication of abdominopelvic surgery. Although patients may respond to nonoperative management, many require surgery. We retrospectively studied patients admitted to Mount Sinai Hospital with a diagnosis of complete ASBO to determine outcomes of nonoperative management. Patients admitted with complete ASBO from 2001 to 2011 were included. Patients with no previous abdominopelvic surgery, surgery within the six weeks preceding admission and obstruction due to other identifiable causes, such as incarcerated hernia, were excluded. Complication rates and outcomes were compared between patients managed with immediate surgery and those managed initially with non-operative strategies. Of 460 patients admitted with complete ASBO, 106 (23.0%) had surgery within 24 hours of admission. At surgery, 20 (18.9%) had ischemic bowel and 8 (7.5%) had perforations. The remaining 354 patients had a trial of nonoperative management lasting at least 24 hours. Of 354 patients managed initially without surgery, 100 (28.2%) patients were discharged without operative intervention during their index admissions. Among the patients having surgery more than 24 hours after admission, indications for surgery were generally failure to resolve, worsening clinical status, and change in imaging findings. Of those patients observed for at least 24 hours, 40 (15.7%) were found to have ischemic bowel and 5 (2.0%) had perforation at surgery. Rates of bowel resection, stoma creation and postoperative complications were similar for the immediate and delayed surgery groups. Among the delayed surgery group, 71 (28.0%) required a bowel resection and 11 (4.3%) stoma creation. Twenty one per cent had postoperative complications, most commonly ileus. There were no statistically significant differences in the outcomes between immediate and delayed groups regardless of duration of delay. Among patients observed with complete ASBO, 24.6 per cent of patients with adhesive obstruction resolved without surgery or readmission. Delaying operative management did not affect surgical findings or complication rates.

How many sunsets? Timing of surgery in adhesive small bowel obstruction: a study of the Nationwide Inpatient Sample

BACKGROUND

Best practices promulgated by the Eastern Association for the Surgery of Trauma suggest that delay in surgery for adhesive small bowel obstruction (ASBO) should not exceed 5 days. This study aimed to probe the relationship between operative delay and adverse outcomes, defined as occurrence of a complication, requirement for bowel resection, prolonged postoperative stay, or death in ASBO using the Nationwide Inpatient Sample.

METHODS

We used the Nationwide Inpatient Sample for 2009. The relationship among days to surgery (preoperative days) and defined as occurrence of a defined set of complications, death during hospitalization, resection, and postoperative length of stay greater than 7 days (postoperative days > 7) was assessed, taking into account potential confounding factors using regression analysis.

RESULTS

A total of 27,046 patients were identified with small bowel obstruction; 4,826 (18%) of these required surgery, and the remainder did not, staying a mean of 4 days (median, 3 days). Of the surgical group, 1,208 patients (25.0%) had Rsx, 1,527 (32%) had postoperative days of greater than 7, 138 (2.86%) died, 3,216 (66.7%) were female. Mean age was 62.2 years, mean total length of stay was 8.51 days, mean preoperative days was 1.94 days. Odds ratio (OR) of death for operated patients was 1.64 (95% confidence interval [CI], 1.11-2.19) when preoperative days was 4 or more. Postoperative days of greater than 7 was more likely if surgery preoperative days were 4 or more (OR, 1.26; 95% CIs, 1.07-1.48). No relationship between complication and preoperative days was observed.

CONCLUSION

Delay in management of small bowel obstruction is associated with death and longer postoperative stays. Delay was not associated with complication or bowel resection. These data lend support to a policy encouraging observation of ASBO for no more than 5 days.

LEVEL OF EVIDENCE

Epidemiologic study, level III; therapeutic study, level IV.

Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

Small-bowel obstruction (SBO) represents as many as 16% of surgical admissions and more than 300,000 operations annually in the United States. The optimal strategies for the diagnosis and management of SBO continue to evolve secondary to advances in imaging techniques, critical care, and surgical techniques. This updated systematic literature review was developed by the Eastern Association for the Surgery of Trauma to provide up-to-date evidence-based recommendations for SBO.

METHODS

A search of the National Library of Medicine MEDLINE database was performed using PubMed interface for articles published from 2007 to 2011.

RESULTS

The search identified 53 new articles that were then combined with the 131 studies previously reviewed by the 2007 guidelines. The updated guidelines were then presented at the 2012 annual EAST meeting.

CONCLUSION

Level I evidence now exists to recommend the use of computed tomographic scan, especially multidetector computed tomography with multiplanar reconstructions, in the evaluation of patients with SBO because it can provide incremental clinically relevant information over plains films that may lead to changes in management. Patients with evidence of generalized peritonitis, other evidence of clinical deterioration, such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain, or patients with evidence of ischemia on imaging should undergo timely exploration. The remainder of patients can safely undergo initial nonoperative management for both partial and complete SBO. Water-soluble contrast studies should be considered in patients who do not clinically resolve after 48 to 72 hours for both diagnostic and potential therapeutic purposes. Laparoscopic treatment of SBO has been demonstrated to be a viable alternative to laparotomy in selected cases.

Bowel obstruction and hernia

Bowel obstruction and abdominal hernia are commonly observed in patients seeking emergency care for abdominal pain. This article discusses bowel obstruction, adynamic ileus, acute colonic pseudo-obstruction, and abdominal hernias, with particular emphasis on the management of patients in the emergency department (ED). Although the diagnostic approach to bowel obstruction often requires imaging, abdominal hernia may be identified in most circumstances by history and physical examination alone. Urgent surgical consultation is indicated when there is a concern for bowel ischemia, strangulation, or complete obstruction. This article reviews an ED-based approach to the patient presenting with symptoms of bowel obstruction or hernia.

Strategies for diagnosis and treatment of small bowel obstruction

Small bowel obstruction, which is caused by a variety of etiological factors and mainly manifests as abdominal pain, vomiting and distension, is one of the most common acute abdomens. A rapid and accurate diagnosis of small bowel obstruction is needed to give reasonable and effective treatment to avoid its rapid deterioration. In this paper we discuss the strategies for diagnosis and treatment of small bowel obstruction through comparing different imaging methods for diagnosis of small bowel obstruction and reviewing the current situation of diagnosis and treatment of the disease in terms of pharmacotherapy, gastrointestinal decompression, and surgical intervention.

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.