New paradigms in the treatment of small bowel obstruction

Meckel’s Diverticulum Causing a Small Bowel Obstruction in an 80-Year-Old Male: Report of a Rare Case and Review of the Literature

Meckel's diverticulum (MD) is the most common congenital malformation occurring in the gastrointestinal tract and results from the persistence of the vitelline duct during embryology. MD is typically asymptomatic in adults with most of its symptoms manifesting in early childhood. Small bowel obstruction (SBO) due to MD in the elderly population is an entity that has not been widely described in the literature. We present a very rare case of SBO in an 80-year-old patient with no previous abdominal surgeries (virgin abdomen). The cause of obstruction was determined to be an adhesive band formed on top of an MD. The obstruction was relieved and the small bowel segment that contained the diverticulum was resected, and anastomosis was made.

Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study

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.

Small bowel obstruction secondary to a plastic bezoar

We present a case of a small bowel obstruction secondary to a rare plastic bezoar. A man in their early 20s with autism and an intellectual disability presented with symptoms of small bowel obstruction. CT revealed very subtle signs and, despite passage of gastrografin, ongoing clinical suspicion led to operative management which confirmed the diagnoses of plastic bezoar.

Clinical efficacy of acupuncture in patients with adhesive intestinal obstruction: A meta-analysis

BACKGROUND

Adhesive intestinal obstruction (AIO) is a common surgical emergency. Surgical exploration has a considerable risk of intestinal injury, and surgical treatment may greatly reduce the quality of life after surgery and cause AIO after re-operation. The nonsurgical treatment is effective for approximately 70% to 90% of patients with adhesive small bowel obstruction (ASBO). However, the high recurrence (30%) and mortality (2%) rates of ASBO are concerning. Moreover, the ideal management method of ASBO remains debatable. Studies have shown that acupuncture can also promote postoperative gastrointestinal function recovery and prevent postoperative complications such as nausea, vomiting, and visceral pain.

AIM

We aimed to evaluate the effectiveness of acupuncture in the treatment of AIO.

METHODS

Randomized controlled trials investigating the effectiveness of acupuncture for adhesive bowel obstruction published until November 2021 were identified by searching 8 comprehensive databases. Data analysis was performed using RevMan v. 5.4 and Stata software v. 16.0. The random-effects model and the fixed-effects model were used to perform the meta-analysis on the experimental group and control group.

RESULTS

Twelve studies with a total of 892 participants were included. The results showed that the experimental group had a significantly higher effective rate (relative risk: 1.20; 95% confidence interval (CI): 1.11-1.28; P < .00001) and a markedly shorter time of the first defecation (mean difference: -11.49, 95% CI: -19.31 to -3.66; P = .004) than the control group. The experimental group also showed a reduction in the duration of abdominal pain, and the reduced length of hospital stay. However, no statistical differences were observed between the 2 groups in terms of the surgery conversion rate.

CONCLUSION

Acupuncture is effective in the treatment of AIO. It can remarkably alleviate some clinical symptoms in patients with AIO.

Non-operative Management of Small Bowel Obstruction in Patients with No Previous Abdominal Surgery: A Systematic Review and Meta-analysis

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.

Non-operative management for small bowel obstruction in a virgin abdomen: a systematic review

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.

Accuracy of Computed Tomography in Small Bowel Obstruction

Small bowel obstruction is a common clinical occurrence, primarily caused by adhesions. The diagnosis is usually made on the clinical findings and the presence of dilated bowel loops on plain abdominal radiograph. Computed tomography (CT) is increasingly used to diagnose the cause and location of the obstruction to aid in the timing of surgical intervention. We used a retrospective chart review to identify patients with a diagnosis of small bowel obstruction between 2009 and 2012. We compared the findings on CT with the findings at operative intervention. Sixty patients had abdominal CT and subsequent surgical intervention. Eighty-three per cent of CTs were correct for small intestine involvement and 80 per cent for colon involvement. The presence of adhesions or perforation was correctly identified in 21 and 50 per cent, respectively. Sixty-four per cent correctly identified a transition point. The presence of a mass was correctly identified in 69 per cent. Twenty per cent of the patients who had ischemic small bowel at surgery were identified on CT. CT has a role in the clinical assessment of patients with small bowel obstruction, identifying with reasonable accuracy the extent of bowel involvement and the presence of masses and transition points. It is less reliable at identifying adhesions, perforations, or ischemic bowel.

Diagnostic significance of multidetector computed tomography (MDCT) in patients with small bowel obstruction: a meta-analysis

PURPOSE

To assess the diagnostic value of multidetector computed tomography (MDCT) in small bowel obstruction (SBO) patients.

METHODS

Relevant literature was searched from the Cochrane Library, Pubmed and Embase. The extracted effective data was calculated using the Meta-Disc 1.4 software; statistical heterogeneity was evaluated using Cochran's Q test and I².

RESULTS

A total of five articles were selected for the meta-analysis. In addition, the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), as well as the diagnostic odds ratio (DOR) were 0.878 (95% CI 0.822-0.921), 0.807 (95% CI 0.753-0.854), 8.137 (95% CI 2.268-29.192), 0.127 (95% CI 0.040-0.4078) and 72.384 (95% CI 10.841-483.31), respectively. Furthermore, the AUC was 0.9648 with the Q of 0.9116.

CONCLUSIONS

The data suggest that MDCT is an effective method for diagnosis of SBO.

Outcomes in adhesive small bowel obstruction from a large statewide database: What to expect after nonoperative management

BACKGROUND

Although adhesive small-bowel obstruction (ASBO) is frequently managed nonoperatively, little is known regarding outcomes on readmission following this approach. Using a large population-based dataset, we evaluated risk factors for operative intervention and mortality at readmission in patients with ASBO who were initially managed nonoperatively.

METHODS

The ASBO patients were identified in the California Office of Statewide Health Planning and Development 2007 to 2014 patient discharge database. Patients who were managed operatively at index admission or had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for nonadhesive obstructive small bowel disease were excluded. Associations between risk factors and both operative intervention and death following readmission were evaluated using survival analysis.

RESULTS

Among 15,963 ASBO patients, 3,103 (19.4%) had at least one readmission. The 1,069 (34.5%) who received an operation during their first readmission presented sooner (175 days vs. 316 days, p < 0.001) and were more likely to die during that readmission (5.2% vs. 0.7%, p < 0.001). Operative management at first readmission was associated with younger age, fewer comorbidities, and shorter times to readmission. Patients operatively managed at first readmission had longer times to second readmission compared with nonoperative patients. Stratified analyses using nonoperative patients as the reference over the study period revealed that patients who underwent lysis of adhesions and bowel resection were 5.04 times (95% confidence interval [CI], 2.82-9.00) as likely to die while those who underwent lysis only were 2.09 times (95% CI, 1.14-3.85) as likely to die. Patients with bowel resection only were at an increased risk for subsequent interventions beyond the first readmission (hazard ratio, 1.79; 95% CI, 1.11-2.87).

CONCLUSION

In a large cohort readmitted for ASBO and initially managed nonoperatively, subsequent operative intervention conferred a greater risk of death and a longer time to readmission among survivors. Prospective research is needed to further delineate outcomes associated with initial nonoperative management of ASBO.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

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.

Small Bowel Obstruction

Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.

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.

Small Bowel Obstructions in a Virgin Abdomen: Is an Operation Mandatory?

Though conventionally not considered standard of care, nonoperative management of patients with small bowel obstruction (SBO) without previous abdominal operations, so called “virgin abdomens,” (VA) is presently being practiced. We aimed to determine outcomes of patients with VA undergoing operative and nonoperative management of SBO. A retrospective review of patients with SBO was performed; outcomes of patients with VA were analyzed. SBO with a VA was found in 103 patients over a 5-year period. With a mean follow-up of 4.5 years, nonoperative management was associated with successful resolution of obstruction in 61 per cent (63/103) of patients. Of those managed nonoperatively, 58/63 (92.1%) did not experience a recurrence. Of the 21 patients with a complete/high-grade SBO on imaging, 16 (76.2%) were managed operatively. Of the 64 patients with a partial/low-grade obstruction or partial obstruction/ileus on imaging, 53 (82.8%) were managed nonoperatively. These data suggest that selected patients with SBO and a VA may safely undergo nonoperative management under close surgical monitoring.

Small bowel obstruction in the virgin abdomen: time to challenge surgical dogma with evidence

BACKGROUND

Although adhesions account for more than 70% of small bowel obstruction (SBO), they are thought to be less likely aetiologies in patients without previous abdominal surgery. Expedient surgery has historically been advocated as prudent management in these patients. Emerging evidence appears to challenge such a dogmatic approach.

METHODS

A retrospective analysis was performed in all SBO patients with a virgin abdomen admitted between January 2012 and August 2014. Patients with obstruction secondary to abdominal wall hernias were excluded. Patient demographics, clinical presentation, management strategy and pathology involved were reviewed.

RESULTS

A total of 72 patients were included in the study. The majority of patients were males (66.7%), with a median age of 58 years (range: 23-101). Abdominal pain (97%) and vomiting (86%) were the most common presentations while abdominal distention (60%) and constipation (25%) were reported less frequently. Adhesions accounted for the underlying cause in 44 (62%) patients. Other aetiologies included gallstone ileus (n = 5), phytobezoar (n = 5), intussusception (n = 4), internal herniation (n = 4), newly diagnosed small bowel tumour (n = 3), mesenteric volvulus (n = 3), stricture (n = 3) and Meckel's diverticulum (n = 1). Twenty-nine (40%) patients were successfully managed conservatively while the remaining 43 (60%) underwent surgery. The intraoperative findings were in concordance with the preoperative computed tomography scan in 76% of cases.

CONCLUSION

Adhesions remain prevalent despite the absence of previous abdominal surgery. Non-operative management is feasible for SBO in a virgin abdomen. Computed tomography scan can be a useful adjunct in discerning patients who may be treated non-operatively by elucidating the underlying cause of obstruction.

Percutaneous needle decompression in treatment of malignant small bowel obstruction

AIM: To investigate the efficacy and safety of percutaneous needle decompression in the treatment of malignant small bowel obstruction (MSBO).

METHODS: A prospective analysis of the clinical data of 52 MSBO patients undergoing percutaneous needle decompression was performed.

RESULTS: Percutaneous needle decompression was successful in all 52 patients. Statistically significant differences were observed in symptoms such as vomiting, abdominal distension and abdominal pain before and after treatment (81.6% vs 26.5%, 100% vs 8.2%, and 85.7% vs 46.9%, respectively; all P < 0.05). The overall significantly improved rate was 19.2% (11/52) and the response rate was 94.2% (49/52) using decompression combined with nasal tube placement, local arterial infusion of chemotherapy and nutritional support. During the one-month follow-up period, puncture-related complications were acceptable.

CONCLUSION: Percutaneous needle intestinal decompression is a safe and effective palliative treatment for MSBO.

Laparoscopy for small bowel obstruction in children--an update

INTRODUCTION

We evaluated the current role of minimally invasive surgery (MIS) in children with small bowel obstruction (SBO) at our institution.

SUBJECTS AND METHODS

A retrospective review of patients undergoing MIS for acute SBO was performed from 2008 to 2013. The study population was compared with a historical control including patients from 2001 to 2008.

RESULTS

There were 71 patients who met inclusion criteria; 35 were male, and 36 were female. Sixty-two children underwent laparoscopy for their first episode of SBO, and 12 underwent laparoscopy for recurrent SBO, accounting for 74 episodes of SBO managed with MIS. The most common etiology of SBO was adhesions (n=40). Laparoscopy and laparoscopic-assisted procedures were associated with shorter nasogastric tube decompression (1.4±2 days [P<.001] and 1.5±2.7 days [P=.002], respectively) and time to regular diet (3.9±4 days [P=.002] and 4.6±2.8 days [P=.024], respectively) compared with those converted to laparotomy (5.1±4.9 days of nasogastric tube decompressions and 8±4.7 days to regular diet). There was no difference in postoperative morbidity comparing laparoscopy (11%), laparoscopic-assisted (5%), and laparoscopic converted to open procedures (18%) (P=.48).

CONCLUSIONS

Laparoscopy continues to be a safe diagnostic and therapeutic tool in the management of pediatric SBO.

Conservative treatment of adhesive small bowel obstruction in children: a systematic review

OBJECTIVE

To assess the effectiveness of conservative treatment for adhesive small bowel obstruction (ASBO) in children.

DESIGN

Systematic review of studies involved children with ASBO who received initial conservative/non-operative treatment.

SETTING

The search was performed in April 2013 using PubMed (see online supplementary file 1), current contents, and the Cochrane database.

PARTICIPANTS

Children with ASBO.

INTERVENTIONS

Conservative treatment included nasogastric decompression, parenteral fluids and correction of electrolyte and fluid imbalance.

PRIMARY OUTCOME

Treatment success.

SECONDARY OUTCOMES

Length of hospital stay and the time to first feeding after hospital admission.

RESULTS

7 studies (six retrospective, one prospective), involving 8-109 patients (age: 1 month to 16 years) treated conservatively, were included in the review. The nature of conservative treatment was generally consistent between studies (nasogastric decompression, parenteral fluids and correction of electrolyte and fluid imbalance), although patients in one study also received Gastrografin. The rate of conservative treatment success ranged from 16% to 75% among the five studies, but one trial showed 0% successful rate. The hospital length of stay ranged from 3 to 6.5 days for conservative treatment (vs 10.2-13 days for operative treatment). The time to first feeding ranged from 31 to 84 h for conservative treatment.

CONCLUSIONS

In conclusion, in the majority of cases, conservative treatment is an effective means of managing ASBO in children.

Serum lactate and phosphate as biomarkers of intestinal ischemia in a Ugandan tertiary hospital: a cross-sectional study

Background

Intestinal ischemia is a common complication of intestinal obstruction and arises from impaired perfusion. The resultant local and systemic inflammatory response and bacterial translocation come with a significant degree of morbidity and mortality. This study therefore aimed to investigate the predictive value of elevated levels of serum lactate and phosphate as biomarkers of intestinal ischemia among patients with mechanical intestinal obstruction.

Methods

This was a cross-sectional analytical study done at Mulago Hospital in Uganda. Ethical approval was obtained. All eligible patients had a blood sample drawn for assay analysis. Determination of bowel ischemia status was by physical examination at laparotomy. Analyses were performed using Stata software, version 10.1, and 2 × 2 tables were used to calculate sensitivity and specificity.

Results

Serum lactate was predictive of bowel ischemia, while phosphate was not. Of the 81 patients enrolled 70 qualified for analysis; 40/70 (57%) had ischemic bowel, while 30/70 (43%) had normal bowel. Among those with ischemic bowel, 28/40 (70%) had reversible ischemia, and 12/40 (30%) had irreversible ischemia. Serum lactate assay had a sensitivity of 66% and specificity of 53% for bowel ischemia in general and a higher sensitivity of 71% and specificity of 80% for irreversible bowel ischemia.

Lactate was predictive of bowel ischemia in general (p = 0.011), PPV = 14%, but more significantly predictive of irreversible ischemia (p = 0.009), PPV = 42%. NPV for lactate in both forms of ischemia was 93%. Hernias (33/70, 47%) were the most common cause of intestinal obstruction.

Conclusion

Serum lactate assay had moderate sensitivity for bowel ischemia due to acute mechanical intestinal obstruction. The assay can be used to aid diagnosis of bowel ischemia in low technology settings.

Small bowel obstruction and perforation attributed to tubo-ovarian abscess following 'D' and 'C'

We report the case of a young woman who was admitted because of small bowel obstruction and localized peritonitis following a dilatation and curettage ('D’ and 'C’) of uterus in abortion. As infection, like tubo-ovarian abscess may complicate any abortion, it seems wise to ensure that it does not exist prior to performing a 'D’ and 'C’.

Application of naso-intestinal decompression tubes in patients with acute paralytic intestinal obstruction

AIM: To explore the use of naso-intestinal decompression tubes (NDTs) in patients with acute paralytic intestinal obstruction.

METHODS: Clinical data for 48 patients with acute paralytic intestinal obstruction treated from November 2010 to March 2013 were retrospectively analyzed. NDTs were placed under gastroscopic guidance to the upper jejunum to conduct gastrointestinal decompression in 21 cases (treatment group), and traditional nasal gastric tubes were placed to perform conventional gastrointestinal decompression in 27 cases (control group). Gastrointestinal drainage volume, waist circumference reduction, indwelling time, length of hospital stay, catheter obstruction rate and mortality rate were compared between the two groups.

RESULTS: Drainage volume (926 mL ± 243 mL vs 926 mL ± 243 mL, P < 0.05) and waist circumference reduction (12.6 cm ± 4.1 cm vs 5.4 cm ± 3.5 cm, P < 0.05) were significantly more in the treatment group than in the control group. The rate of catheter obstruction (4.8% vs 40.7%, P < 0.05), indwelling time (8.3 d ± 3.9 d vs 13.4 d ± 5.6 d, P < 0.05), and hospitalization time (12.1 d ± 4.8 d vs 17.5 d ± 6.1d, P < 0.05) were significantly lower in the treatment group than in the control group. No significant difference was found in mortality between the two groups (4.76% vs 7.40%, P > 0.05).

CONCLUSION: NDTs are superior to traditional nasogastric tubes in the management of acute paralytic intestinal obstruction.