Current management of small bowel obstruction in the UK: results from the National Audit of Small Bowel Obstruction clinical practice survey

Laparoscopic Management of Acute Small Bowel Obstruction: A Retrospective Study at a Tertiary Center in the United Kingdom

Objectives To present a single-center experience of laparoscopic management of acute small bowel obstruction (ASBO) based on seven years of data and demonstrate its suitability for the United Kingdom (UK). Methods A retrospective review of case notes to evaluate postoperative outcomes was conducted. All emergency small bowel obstructions treated laparoscopically were included. The cases that were converted to a laparotomy were excluded. Demographics (age, sex), American Society of Anesthesiologists (ASA) grade, indication for surgery, duration of stay, complications, requirement of stoma, requirement of intensive treatment unit/high dependency unit (ITU/HDU), reoperation/readmissions, and 30-day mortality were noted. The results were tabulated and analyzed accordingly. Results There were 119 patients studied, with a median age of 66 (range: 17-97). The sex ratio was 62 females to 57 males. Primary etiologies of adhesion bands (49.5%, 59) and hernia (31.9%, 38) were the most common. Minor and major complications were 15 (12.6%) and 37 (31%), respectively. Three (2.5%) patients passed away within 30 days of surgery. The median length of stay (LOS) was eight days. The median LOS subgroup analysis showed nine days for adhesiolysis and six days for hernias. Discussion This study shows that there is significant heterogeneity in outcomes regarding small bowel obstruction around the world. We have demonstrated similar to better results in our center relative to other prominent centers in the UK. This can be attributed to the patient cohort, presentation, and physiological status on admission, delay to surgery, and associated co-morbidities to name a few. Conclusion This study indicates that laparoscopic surgery is a safe approach to treating ASBO, provided adequate expertise and infrastructure are available.

Keys to successful laparoscopic adhesiolysis for adhesive small bowel obstruction: A scoping review

Background

Adhesive small bowel obstruction (ASBO) is a common acute abdominal complication. Although non-surgical treatment is the primary treatment approach, more and more studies show that surgical treatment can reduce the incidence rate. Laparoscopic adhesiolysis (LA) has many advantages of minimally invasive surgery.But not all patients with ASBO are suitable for LA.

Objective

The aim of this scoping review was to summarize the keys to successful LA by analyzing the extensive literature.

Methods

A literature search was conducted in PubMed for articles on laparoscopic treatment of ASBO published between January 2000 and February 2024. This scoping review followed the framework suggested by Arksey and O'Malley for a scoping review.

Results

By analyzing the included studies we found that LA does have many advantages and can be performed safely. However, the prerequisite is to select patients with simple adhesions whenever possible and to focus on reasonable intraoperative measures. To improve the success rate of LA, we summarized the following characteristics of patients: no contraindications related to pneumoperitoneum, few previous abdominal operations (≤2), no pregnancy, bowel dilatation < 4 cm in diameter, simple adhesions, no diffuse peritonitis, no history of abdominal radiotherapy, <24 h of ASBO, limited previous abdominal surgery (appendix, cholecystectomy), no bowel strangulation ischemia, and bowel necrosis or bowel resection required for other reasons. In addition, we also summarized reasonable intraoperative measures.

Conclusions

Laparoscopic adhesiolysis has many advantages.Specific patients can benefit from LA. This scoping review Summarized the conditions for patient screening and reasonable intraoperative measures with the aim of providing a reference for surgeons, thereby ensuring that more patients benefit from LA.

Malnutrition in emergency general surgery: a survey of National Emergency Laparotomy Audit Leads

BACKGROUND

Patients who are malnourished and have emergency general surgery, such as a laparotomy, have worse outcomes than those who are not malnourished. It is paramount to identify these patients and minimise this risk. This study aimed to describe current practices in identifying malnutrition in patients undergoing a laparotomy, specifically focusing on screening, assessment, nutrition pathways and barriers encountered by clinicians.

METHODS

Following piloting and validity assessment, anaesthetic and surgical National Emergency Laparotomy Audit (NELA) Leads at hospitals across England and Wales were emailed an invitation to a survey. Responses were gathered using Qualtrics. Descriptive analysis and correlation with laparotomy volume and professional role were performed in SPSSv26. University of Sheffield ethical approval was obtained (UREC 046205). The results from the survey are reported according to the CHERRIES guidelines.

RESULTS

The survey was completed by 166/289 NELA Leads from 117/167 hospitals (57.4% and 70.1% response rates, respectively). Participants reported low rates of nutritional screening (42/166; 25.3%) and assessment (26/166; 15.7%) for malnutrition preoperatively. More than one third of respondents (40.1%) had no awareness of local screening tools; indeed, the Malnutrition Universal Screening Tool (MUST) was used by approximately half of respondents (56.6%). Contrary to guidelines, NELA Leads report albumin levels continue to be used to determine malnutrition risk (73.5%; 122/166). Postoperative nutrition pathways were common (71.7%; 119/166). Reported barriers to nutritional screening and assessment included a lack of time, training and education, organisational support and ownership. Participants indicated nutrition risk is inadequately identified and is an important missing data item from NELA. There was no significant correlation with hospital laparotomy volume in relation to screening or assessment for malnutrition, the use of nutritional support pathways or organisational barriers. There was interprofessional agreement across a number of domains, although some differences did exist.

CONCLUSIONS

Wide variation exists in the current practice of identifying malnutrition risk in NELA patients. Barriers include a lack of time, knowledge and ownership. Nutrition pathways that encompass the preoperative phase and incorporation of nutrition data in NELA may support improvements in care.

[Comparison of early operative treatment and 48-hour conservative treatment in small bowel obstruction (COTACSO): intermediate results]

Optimal treatment for adhesive small bowel obstruction (SBO) is not defined. Surgery is the only method of treatment for obvious strangulating SBO. Non-operative management (NOM) is widely used among patients with low risk of strangulation, i.e. no clinical, laboratory and CT signs. Randomized controlled trials (RCTs) are recommended to determine the optimal method (early intervention or NOM), but their safety is unclear due to possible delay in surgery for patients needing early intervention.

MATERIAL AND METHODS

A RCT is devoted to outcomes of early operative treatment and NOM for adhesive SBO. The estimated trial capacity is 200 patients. Thirty-two patients were included in interim analysis. In 12 hours after admission, patients without apparent signs of strangulation were randomized into two clinical groups after conservative treatment. Group I included 12 patients who underwent immediate surgery, group II - 20 patients after 48-hour NOM. The primary endpoint was success of non-surgical regression of SBO and reduction in mortality. To evaluate patient safety, we analyzed mortality, complication rates and bowel resection in this RCT with previously published studies.

RESULTS

In group I, all 12 (100%) patients underwent surgery. Only 4 (20%) patients required surgery in group II. Mortality, complication rates and bowel resection rates were similar in both groups. Strangulating SBO was found in 8 (25%) patients. Overall mortality was 6.3%, bowel resection rate - 6.3%, iatrogenic perforation occurred in 3 (18.8%) patients. These values did not exceed previous findings.

CONCLUSION

Non-operative management within 48 hours prevented surgery in 80% of patients with SBO. Interim analysis found no significant between-group differences in mortality, complication rates and bowel resection rate. Patients had not been exposed to greater danger than other patients with adhesive SBO. The study is ongoing.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Survey of Diagnostic and Management Practices in Small Bowel Obstruction: Individual and Generational Variation Despite Practice Guidelines

Background: Small bowel obstruction (SBO) is a common disorder managed by surgeons. Despite extensive publications and management guidelines, there is no universally accepted approach to its diagnosis and management. We conducted a survey of acute care surgeons to elucidate their SBO practice patterns.Methods: A self-report survey of SBO diagnosis and management practices was designed and distributed by email to AAST surgeons who cared for adult SBO patients. Responses were analyzed with descriptive statistics and Chi-square test of independence at α = .05.Results: There were 201 useable surveys: 53% ≥ 50 years, 77% male, 77% at level I trauma centers. Only 35.8% reported formal hospital SBO management guidelines. Computed tomography (CT) scan was the only diagnostic exam listed as "essential" by the majority of respondents (82.6%). Following NG decompression, 153 (76.1%) would "always/frequently" administer a water-soluble contrast challenge (GC). There were notable age differences in approach. Compared to those ≥50 years, younger surgeons were less likely to deem plain abdominal films as "essential" (16.0% vs 40.2%; P < .01) but more likely to require CT scan (88.3% vs 77.6%; P = .045) for diagnosis and to "always/frequently" administer GC (84.0% vs 69.2%; P < .01). Younger surgeons used laparoscopy "frequently" more often than older surgeons (34.0% vs 21.5%, P = .05).Discussion: There is significant variation in diagnosis and management of SBO among respondents in this convenience sample, despite existing PMGs. Novel age differences in responses were observed, which prompts further evaluation. Additional research is needed to determine whether variation in practice patterns is widespread and affects outcomes.

Laparoscopic adhesiolysis versus open adhesiolysis in acute adhesive small bowel obstruction

Introduction

Exploratory laparotomy is still the standard therapy for patients who need surgical intervention for adhesive small bowel obstruction (SBO). However, the use of laparoscopy in the management of adhesive SBO is still controversial. We aimed to detect the short-term outcomes between open and laparoscopic adhesiolysis for SBO.

Patients and Methods

This is a retrospective study of patients with adhesive SBO who underwent either laparoscopic or open surgery from June 2019 to July 2022 at Ain Shams University Hospitals. Intraoperative and early post-operative outcomes were compared in the two groups.

Results

A total of 89 patients with adhesive SBO were included in our study. Fifty-one cases underwent open adhesiolysis and 38 cases underwent laparoscopic adhesiolysis. Laparoscopic adhesiolysis is associated with a remarkable decrease in the operative time (71 min vs. 107 min, P = 0.001) and blood loss (50 ml vs. 120 ml, P = 0.001) in comparison to open adhesiolysis. In addition to that, those who underwent adhesiolysis by laparoscopy had a short hospital stay (2.4 days vs. 3.8 days, P = 0.001), early recovery (time to pass flatus 1.3 days vs. 2.8 days) and less post-operative complications (surgical site infection [SSI] 2.6% vs. 19.6%, P = 0.001). Moreover, open adhesiolysis is associated with a higher rate of early post-operative mortality. In addition to that, the incidence of iatrogenic injury was higher in the open group.

Conclusion

Laparoscopic adhesiolysis is a safe and feasible approach for the management of SBO and has better short-term outcomes, especially if done by skilled surgeons in advanced laparoscopic techniques.

Is laparoscopic surgery safe and feasible in acute adhesive ileus?

Although the classical surgical treatment of adhesive ileus is performed using the open method, laparoscopic surgery has recently been performed in some centers. This study aimed to discuss the feasibility and role of laparoscopic surgery in the treatment of adhesive small bowel obstruction. In this retrospective study, the data of 830 patients who were operated for ileus in Başkent University Faculty of Medicine, Ankara Hospital, Department of General Surgery between January 2011 and September 2022 were analyzed. Missing data and intraabdominal cancer-related ileus were accepted as exclusion criteria and 648 patients were excluded from the study. The development of adhesion-related ileus and completeness of the data were accepted as inclusion criteria. Data were compared between the 2 groups [open group (OG; 152 cases) and laparoscopic group (LG; 30 cases]). When the patient characteristics were evaluated, it was found that the history of previous abdominal surgery (P < .001) and the number of previous abdominal surgery (P < .001) were statistically significantly higher in OG. Operation time was significantly longer in the LG (P = .022). There were no statistically significant differences between the groups in terms of intraoperative bowel injury (P = .216), bowel resection (P = .284), and stoma creation (P = .331). OG had a significantly higher rate of Clavien-Dindo grade ≥ 3 serious complications (P < .001) and mortality rate (P = .045). The first gas out occurred significantly earlier in the LG (P = .014). Oral intake was initiated earlier in the LG (P = .004). The length of hospital stay was significantly shorter in the LG (P < .001). There was no significant difference between the groups in terms of postoperative ileus, readmission, and reoperation. Laparoscopic surgery can be safely performed for the treatment of selected patients with adhesive small bowel obstruction. In addition, it is advantageous in terms of postoperative recovery.

Variation in the management of adhesive small bowel obstruction in the Netherlands: a prospective cross-sectional study

BACKGROUND

ASBO is a frequent abdominal surgical emergency and a leading cause of morbidity and mortality in emergency surgery. The aim of this study is to provide insight into the current management of adhesive small bowel obstruction (ASBO) and associated outcomes.

METHODS AND MATERIALS

A nationwide prospective cross-sectional cohort study was conducted. All patients with clinical signs of ASBO admitted to participating Dutch hospitals were included during a 6 months inclusion period between April 2019 and December 2020. Ninety-day clinical outcomes were described and compared for nonoperative management (NOM) and laparoscopic and open surgery.

RESULTS

In 34 participating hospitals, 510 patients were included, of whom 382 (74.9%) had a definitive diagnosis of ASBO. Initial management consisted of emergency surgery in 71 (18.6%) patients and NOM in 311 (81.4%) patients, 119 (31.1%) of whom required delayed surgery after failure of NOM. Surgical interventions started laparoscopically in 51.1%, of which 36.1% were converted to laparotomy. Intentional laparoscopy resulted in shorter hospital stays compared with open surgery (median 8.0 vs. 11.0 days; P <0.001) and comparable hospital mortality (5.2 vs. 4.3%; P =1.000). Oral water-soluble contrast use was associated with a decreased length of stay ( P =0.0001). Hospital stay for surgical patients was shorter in patients who were operated on within 72 h of admission ( P <0.001).

CONCLUSION

This nationwide cross-sectional study demonstrates shorter hospital stay in ASBO patients who received water-soluble contrast, were operated within 72 h of admission or were operated with minimally invasive techniques. Results may support the standardization of ASBO treatment.

SURGICAL TREATMENT OF ACUTE SMALL BOWEL OBSTRUCTION: CLINICAL AND LABORATORY PARAMETERS ASSOCIATED WITH STRANGULATION AND EARLY MORTALITY AFTER SURGERY

OBJECTIVE

The aim: The study aimed to evaluate some criteria for preoperative diagnosis of strangulation and significant indicators of the prognosis of short-term outcomes in patients with small bowel obstruction.

PATIENTS AND METHODS

Materials and methods: The results of the treatment of 123 patients aged 18-70 years with SBO were evaluated.

RESULTS

Results: All of these patients underwent emergency surgery, and 22 patients (17.9%) have died. It has been shown that four lab parameters (blood leukocytes, lactate, intestinal fatty acid-binding protein, and C-reactive protein levels) and one instrumental (involving the mesentery of the small intestine, free fluid in the abdomen during CT) with 80% probability or more were associated with the strangulation type of SBO (Λ=0.276, p = 0.000). Three lab indicators (WBC count, serum lactate, and intestinal fatty acid-binding protein levels) and two clinical parameters (abdominal perfusion pressure level and the presence of abdominal sepsis) were associated with early mortality after surgery (Λ=0.626, p = 0.000) with the same probability. Immediate results of the treatment in these patients depended on the development of intra-abdominal complications after surgery (P = 0.024) and the need for early reoperation (P = 0.006) as well as the development of cardiovascular dysfunction (P = 0.000) and respiratory dysfunction (P = 0.000).

CONCLUSION

Conclusions: There were confirmed parameters that were significantly associated with strangulation before surgery and short-term in-hospital mortality with an 80% probability or more. This made it possible to develop new mathematical models for the diagnosis of strangulated bowel obstruction and early postoperative mortality with an accuracy of 84.5% and 84.2%, respectively.

Laparoscopy in high-risk emergency general surgery reduces intensive care stay, length of stay and mortality

PURPOSE

Emergency general surgery patients undergoing laparoscopic surgery are at reduced risk of mortality and may require reduced length of critical care stay. This study investigated the effect of laparoscopy on high-risk patients' post-operative care requirements.

METHODS

Data were retrieved for all patients entered into the NELA database between 2013 and 2018. Only high-risk surgical patients (P-POSSUM predicted mortality risk of ≥ 5%) were included. Patients undergoing laparoscopic and open emergency general surgical procedures were compared using a propensity score weighting approach. Outcome measures included total length of critical care (level 3) stay, overall length of stay and inpatient mortality.

RESULTS

A total of 66,517 high-risk patients received emergency major abdominal surgery. A laparoscopic procedure was attempted in 6998 (10.5%); of these, the procedure was competed laparoscopically in 3492 (49.9%) and converted to open in 3506 (50.1%). Following inverse probability treatment weighting adjustment for patient disease and treatment characteristics, high-risk patients undergoing laparoscopic surgery had a shorter median ICU stay (1 day vs 2 days p < 0.001), overall hospital length of stay (11 days vs 14 days p < 0.001) and a lower inpatient mortality (16.0% vs 18.8%, p < 0.001). They were also less likely to have a prolonged ICU stay with an OR of 0.78 (95% CI 0.74-0.83, p < 0.001).

CONCLUSION

The results of this study suggest that in patients at high risk of post-operative mortality, laparoscopic emergency bowel surgery leads to a reduced length of critical care stay, overall length of stay and inpatient mortality compared to traditional laparotomy.

Evaluating temporal trends and the impact of surgical subspecialisation on patient outcomes following adhesional small bowel obstruction: a multicentre cohort study

PURPOSE

Small bowel obstruction (SBO) is the most common indication for laparotomy in the UK. While general surgeons have become increasingly subspecialised in their elective practice, emergency admissions commonly remain undifferentiated. This study aimed to assess temporal trends in the management of adhesional SBO and explore the influence of subspecialisation on patient outcomes.

METHODS

Data was collected for patients admitted acutely with adhesional SBO across acute NHS trusts in Northern England between 01/01/02 and 31/12/16, including demographics, co-morbidities and procedures performed. Patients were excluded if a potentially non-adhesional cause was identified and were grouped by the responsible consultant's subspecialty. The primary outcome of interest was 30-day inpatient mortality.

RESULTS

Overall, 2818 patients were admitted with adhesional SBO during a 15-year period. There was a consistent female preponderance, but age and comorbidity increased significantly over time (both p < 0.001). In recent years, more patients were managed operatively with a trend away from delayed surgery also evident (2002-2006: 65.7% vs. 2012-2016: 42.7%, p < 0.001). Delayed surgery was associated with an increased mortality risk on multivariable regression analysis (OR: 2.46 (1.46-4.23, p = 0.001)). CT scanning was not associated with management strategy or timing of surgery (p = 0.369). There was an increased propensity for patients to be managed by gastrointestinal (colorectal and upper gastrointestinal) subspecialists over time. Length of stay (p < 0.001) and 30-day mortality (p < 0.001) both improved in recent years, with the best outcomes seen in colorectal (2.6%) and vascular subspecialists (2.4%). However, following adjustment for confounding variables, consultant subspecialty was not a predictor of mortality.

CONCLUSION

Outcomes for patients presenting with adhesional SBO have improved despite the increasing burden of age and co-morbidity. While gastrointestinal subspecialists are increasingly responsible for their care, mortality is not influenced by consultant subspecialty.

Patient preferences and current practice for adults with steroid-resistant ulcerative colitis: POPSTER mixed-methods study

BACKGROUND

Corticosteroids are a mainstay of the treatment of moderately severe relapses of ulcerative colitis, yet almost 50% of patients do not respond fully to these and risk prolonged steroid use and side effects. There is a lack of clarity about the definitions of steroid resistance, the optimum choice of treatment, and patient and health-care professional treatment preferences.

OBJECTIVES

The overall aim of this research was to understand how steroid-resistant ulcerative colitis is managed in adult secondary care and how current practice compares with patient and health-care professional preferences.

DESIGN

A mixed-methods study, including an online survey, qualitative interviews and discrete choice experiments.

SETTING

NHS inflammatory bowel disease services in the UK.

PARTICIPANTS

Adults with ulcerative colitis and health-care professionals treating inflammatory bowel disease.

RESULTS

We carried out a survey of health-care professionals (n = 168), qualitative interviews with health-care professionals (n = 20) and patients (n = 33), discrete choice experiments with health-care professionals (n = 116) and patients (n = 115), and a multistakeholder workshop (n = 9). The interviews with and survey of health-care professionals showed that most health-care professionals define steroid resistance as an incomplete response to 40 mg per day of prednisolone after 2 weeks. The survey also found that anti-tumour necrosis factor drugs (particularly infliximab) are the most frequently offered drugs across most steroid-resistant (and steroid-dependent) patient scenarios, but they are less frequently offered to thiopurine-naive patients. Patient interviews identified several factors influencing their treatment choices, including effectiveness of treatment, recommendations from health-care professionals, route of administration and side effects. Over time, depending on the severity and duration of symptoms and, crucially, as medical treatment options become exhausted, patients are willing to try alternative treatments and, eventually, to undergo surgery. The discrete choice experiments found that the probability of remission and of side effects strongly influences the treatment choices of both patients and health-care professionals. Patients are less likely to choose a treatment that takes longer to improve symptoms. Health-care professionals are willing to make difficult compromises by tolerating greater safety risks in exchange for therapeutic benefits. The treatments ranked most positively by patients were infliximab and tofacitinib (each preferred by 38% of patients), and the predicted probability of uptake by health-care professionals was greatest for infliximab (62%).

LIMITATIONS

The survey and the discrete choice experiments with patients and health-care professionals are limited by their relatively small sample sizes. The qualitative studies are subject to selection bias. The timing of the different substudies, both before and during the COVID-19 pandemic, is a potential limitation.

CONCLUSIONS

We have identified factors influencing treatment decisions for steroid-resistant ulcerative colitis and the characteristics to consider when choosing treatments to evaluate in future randomised controlled trials. The findings may be used to improve discussions between patients and health-care professionals when they review treatment options for steroid-resistant ulcerative colitis.

FUTURE WORK

This research highlights the need for consensus work to establish an agreed definition of steroid resistance in ulcerative colitis and a greater understanding of the optimal use of tofacitinib and surgery for this patient group. A randomised controlled trial comparing infliximab with tofacitinib is also recommended.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 41. See the NIHR Journals Library website for further project information.

[Surgical approach for small bowel obstruction in the Russian Federation. National survey of surgeons]

OBJECTIVE

To study surgical approach for small bowel obstruction (SBO) regarding national and international guidelines.

MATERIAL AND METHODS

Considering literature data, national and international guidelines and clinical practice, we have formulated 15 questions regarding surgical approach for non-neoplastic SBO. Questions were sent by e-mail to the members of the Russian Society of Surgeons. Survey lasted 60 days. We used the program that provides the respondent with the possibility of visual control of survey results. Survey results were compared with national and international clinical guidelines, Russian- and English-language scientific publications. Restriction of the number of votes >1 and identification of respondents were not provided by the program. There was no reward for survey. A summary is provided on the main issues.

RESULTS

There were 557 respondents (3.0% of surgeons in the Russian Federation). We obtained 481-620 answers for each question.

CONCLUSION

This study is a valuable tool for primary assessment of current surgical practice for SBO in the Russian Federation. Study design did not imply conclusions on the optimal strategy based on opinions of majority of respondents. According to our survey, a significant number of respondents use the treatment strategy that differ from clinical guidelines. Their approach is based on their own clinical experience and local guidelines for the treatment of SBO. Less than half of the answers matched to national clinical guidelines, less than 10% - to the WSES guidelines. Despite the formal coincidence of some statements in national clinical guidelines and English-language recommendations, significant nonconformities require scientific discussion.

Laparoscopic management of gallstone ileus: A case report and literature review

Introduction and importance

Gallstone ileus is an uncommon complication of cholelithiasis. It is usually presented as a small bowel obstruction. Elderly patients are commonly affected. The diagnosis is challenging, since needs a high index of suspicion and imagenology is key. Surgery is the mainstay management, most commonly performed by laparotomy, but laparoscopy is summing cases. Nevertheless the approach is still controversial. We report a gallstone ileus case, that was managed totally laparoscopic in our medium complex public institution.

Case presentation

An 71 years-old male patient, with symptomatic cholelithiasis, consulted in emergency department with symptoms and signs of small bowel obstruction. Computed tomography of abdomen and pelvis showed the classical Rigler's triad. Totally laparoscopic enterolithotomy alone was performed successfully. Postoperative evolution was without incidents, being discharge at fifth day.

Clinical discussion

Gallstone ileus represents around 0,3–0,5% of cholelithiasis complications. Mostly affect elderly women patients, with comorbidities. Mortality and morbidity is still high nowadays. The classical management of gallstone ileus is the open surgery, but the laparoscopic approach has been described and it can be done.

Conclusion

The laparoscopic management of gallstone ileus is effective and secure procedure and seems reasonable to attempt if the conditions and skills are available.

•

Gallstone ileus is an uncommon complication of cholelithiasis.

•

Mostly affect elderly women patients, with comorbidities.

•

Mortality and morbidity is still high nowadays.

•

The diagnosis is difficult to accomplish.

•

The classical management of gallstone ileus is the open surgery, but the laparoscopic management of gallstone ileus is effective and secure procedure.

Facing the unexpected: unusual causes of mechanical small bowel obstruction in adults

Mechanical small bowel obstruction in adults is a common emergency condition that typically requires hospitalisation and usually acute surgical intervention. The majority of the cases are due to adhesive obstruction or common abdominal wall hernias or relevant related past history. However, the surgeons might face unexpected challenges in this concept due to rare causes of this condition. This paper explores in depth the challenges encountered by the emergency general surgeons in the concept of management of rare causes of mechanical small bowel obstruction in adults through a systematic review and critical analysis of the available evidence, and summarises the essential intra-operative steps that are needed to be taken accordingly. In conclusion, the emergency surgeons should be familiar with the uncommon/rare causes of mechanical small bowel obstruction in adults to avoid serious complications. Successful outcomes are based on the combination of high index of clinical suspicion, familiarity with the standard anatomy and its variations, the use of the appropriate radiological investigations and surgical intervention in a timely manner.

An artificial intelligence deep learning model for identification of small bowel obstruction on plain abdominal radiographs

Objectives:

Small bowel obstruction is a common surgical emergency which can lead to bowel necrosis, perforation and death. Plain abdominal X-rays are frequently used as a first-line test but the availability of immediate expert radiological review is variable. The aim was to investigate the feasibility of using a deep learning model for automated identification of small bowel obstruction.

Methods:

A total of 990 plain abdominal radiographs were collected, 445 with normal findings and 445 demonstrating small bowel obstruction. The images were labelled using the radiology reports, subsequent CT scans, surgical operation notes and enhanced radiological review. The data were used to develop a predictive model comprising an ensemble of five convolutional neural networks trained using transfer learning.

Results:

The performance of the model was excellent with an area under the receiver operator curve (AUC) of 0.961, corresponding to sensitivity and specificity of 91 and 93% respectively.

Conclusion:

Deep learning can be used to identify small bowel obstruction on plain radiographs with a high degree of accuracy. A system such as this could be used to alert clinicians to the presence of urgent findings with the potential for expedited clinical review and improved patient outcomes.

Advances in knowledge:

This paper describes a novel labelling method using composite clinical follow-up and demonstrates that ensemble models can be used effectively in medical imaging tasks. It also provides evidence that deep learning methods can be used to identify small bowel obstruction with high accuracy.

Traumatic damage to the liver capsule: an unusual cause of small bowel obstruction

A 61-year-old man presented to the emergency department with severe abdominal pain. Three months prior to presentation, he had sustained blunt trauma to his right side while cycling, but had not sought medical attention. On admission, a CT scan showed small bowel obstruction (SBO) and he underwent an emergency open laparotomy. Intraoperatively, a subcapsular liver haematoma was identified, with incarcerated, necrotic small bowel within the liver capsule. The patient underwent deroofing of the haematoma with an omental patch and a small bowel resection with primary anastomosis. We believe this is the first reported case of SBO secondary to small bowel herniation into the liver capsule following trauma.

Parenteral nutrition in emergency surgery: A multicentre cross-sectional study

BACKGROUND

Emergency general surgical patients are inherently at high risk of malnutrition. Early decision-making with implementation is fundamental to patient recovery. For many patients, parenteral nutrition (PN) is the only feeding option available. The present study assessed the timing and outcomes of this decision-making process.

METHODS

A sample of at least 10 consecutive adult patients admitted as a general surgical emergency to eight UK hospitals over 1 year who had received PN was identified. Patient demographics, basic descriptors and nutritional data were captured. Process measures regarding dates decisions were made or activities completed were extracted from records, as were outcome measures including PN complications. Six time frames examining the process of PN delivery were analysed. Associations between categorical and binary variables were investigated with a chi-squared test with significance determined as p < 0.05.

RESULTS

In total, 125 patients were included. Intestinal obstruction was the most common diagnosis with 59% of all patients deemed high risk on nutritional assessment at admission. Median time to decision for PN was 5 days following admission (n = 122, interquartile range = 7). Patients received PN for a mean of 11 days. Eighty-five percent of patients developed a complication, with a phosphate abnormality being the most commonly reported (54%). Only altered blood glucose levels appeared to correlate with a delay in starting PN (p < 0.01).

CONCLUSIONS

The present study shows there are delays in the decision to use PN in the acutely ill surgical patient. Once initiated, the pathway is relatively short. There are high rates of electrolyte abnormalities in this population.

A national propensity score-matched analysis of emergency laparoscopic versus open abdominal surgery

BACKGROUND

Laparoscopy has been widely adopted in elective abdominal surgery but is still sparsely used in emergency settings. The study investigated the effect of laparoscopic emergency surgery using a population database.

METHODS

Data for all patients from December 2013 to November 2018 were retrieved from the NELA national database of emergency laparotomy for England and Wales. Laparoscopically attempted cases were matched 2 : 1 with open cases for propensity score derived from a logistic regression model for surgical approach; included co-variates were age, gender, predicted mortality risk, and diagnostic, procedural and surgeon variables. Groups were compared for mortality. Secondary endpoints were blood loss and duration of hospital stay.

RESULTS

Of 116 920 patients considered, 17 040 underwent laparoscopic surgery. The most common procedures were colectomy, adhesiolysis, washout and perforated ulcer repair. Of these, 11 753 were matched exactly to 23 506 patients who had open surgery. Laparoscopically attempted surgery was associated with lower mortality (6.0 versus 9.1 per cent, P < 0.001), blood loss (less than 100 ml, 64.4 versus 52.0 per cent, P < 0.001), and duration of hospital stay (median 8 (i.q.r. 5-14) versus 10 (7-18) days, P < 0.001). Similar trends were seen when comparing only successful laparoscopic cases with open surgery, and also when comparing cases converted to open surgery with open surgery.

CONCLUSION

In appropriately selected patients, laparoscopy is associated with superior outcomes compared with open emergency surgery.

The impact of laparoscopy on emergency surgery for adhesional small bowel obstruction: prospective single centre cohort study

INTRODUCTION

Laparoscopic adhesiolysis is increasingly being used to treat adhesional small bowel obstruction (ASBO) as it has been associated with reduced postoperative length of stay (LOS) and faster recovery. However, concerns regarding limited working space, iatrogenic bowel injury and failure to relieve the obstruction have limited its uptake. This study reports our centre's experience of adopting laparoscopy as the standard operative approach.

METHODS

A single-centre prospective cohort study was performed incorporating local data from the National Emergency Laparotomy Audit Database; January 2015 to December 2019. All patients undergoing surgery for ASBO were included. Patient demographic, operative and inhospital outcomes data were compared between different surgical approaches. Linear regression analysis was performed for LOS.

RESULTS

A total of 299 cases were identified. Overall, 76.3% of cases were started laparoscopically and 52.2% were completed successfully. Patients treated laparoscopically had lower Portsmouth - Physiological and Operative Severity Score for the enuMeration of Mortality and morbidity (P-POSSUM) predicted mortality (median 2.1 (interquartile range (IQR) 1.3-5.0) vs 5.7 (IQR 2.0-12.4), p=<0.001) and shorter postoperative LOS compared with open (median 4.2 days (IQR 2.5-8.2) vs 11.3 days (IQR 7.3-16.6), p=0.000). Inhospital mortality was lower in the laparoscopic group (2 vs 7 deaths, p=<0.001). In regression analysis, laparoscopic surgery was found to have the strongest association with postoperative LOS (β -8.51 (-13.87 to -3.16) p=0.002) compared with open surgery.

CONCLUSIONS

Laparoscopy is a safe and feasible approach for adhesiolysis in the majority of patients with ASBO. It is associated with reduced LOS with no impact on complications or mortality.

Adhesive Small Bowel Obstruction and the six w's: Who, How, Why, When, What, and Where to diagnose and operate?

BACKGROUND AND AIMS

Approximately 75% of patients admitted with small bowel obstruction have intra-abdominal adhesions as their cause (adhesive small bowel obstruction). Up to 70% of adhesive small bowel obstruction cases, in the absence of strangulation and bowel ischemia, can be successfully treated with conservative management. However, emerging evidence shows that surgery performed early during the first episode of adhesive small bowel obstruction is highly effective. The objective of this narrative review is to summarize the current evidence on adhesive small bowel obstruction management strategies.

MATERIALS AND METHODS

A review of the literature published over the last 20 years was performed to assess Who, hoW, Why, When, What, and Where diagnose and operate on patients with adhesive small bowel obstruction.

RESULTS

Adequate patient selection through physical examination and computed tomography is the key factor of the entire management strategy, as failure to detect patients with strangulated adhesive small bowel obstruction and bowel ischemia is associated with significant morbidity and mortality. The indication for surgical exploration is usually defined as a failure to pass contrast into the ascending colon within 8-24 h. However, operative management with early adhesiolysis, defined as operative intervention on either the calendar day of admission or the calendar day after admission, has recently shown to be associated with an overall long-term survival benefit compared to conservative management. Regarding the surgical technique, laparoscopy should be used only in selected patients with an anticipated single obstructing band, and there should be a low threshold for conversion to an open procedure in cases of high risk of bowel injuries.

CONCLUSION

Although most adhesive small bowel obstruction patients without suspicion of bowel strangulation or gangrene are currently managed nonoperatively, the long-term outcomes following this approach need to be analyzed in a more exhaustive way, as surgery performed early during the first episode of adhesive small bowel obstruction has shown to be highly effective, with a lower rate of recurrence.

Small bowel obstruction secondary to intramesosigmoid hernia

Intramesosigmoid hernias are a rare cause of small bowel obstruction. Here, we present such a case with learning points derived from diagnostic dilemma, shared decision making in consent and the management of a rare cause of a common surgical emergency.

Adhesional small bowel obstruction related to stapling device from previous laparoscopic inguinal hernia repair

Small bowel obstruction (SBO) is common surgical presenting problem, accounting for roughly 15 000 laparotomies per year in the UK. However, SBO post laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is uncommon with an estimated incidence of 0.2%-0.5%. The common causes for SBO post-TAPP include inadequate closure, port-site herniation and adhesions. Here, we present a case of adhesional SBO related to stapling device from previous laparoscopic inguinal hernia repair and review alternative methods for mesh fixation. This case reports a rare but life-threatening complication from a commonly performed day case procedure and highlights importance of adequate surgical technique when inserting foreign bodies intra-abdominally. The patient required an emergency laparotomy and small bowel resection, developed postoperative ileus which managed with a nasogastric tube, intravenous fluids and parenteral nutrition and was discharged 12 days postoperatively.

Emergency general surgeons, subspeciality surgeons and the future management of emergency surgery: results of a national survey

AIM

This study aimed to survey consultants' experience of working as or with emergency general surgery (EGS) surgeons and to investigate the role they fulfil in the management of general and subspeciality emergencies.

METHOD

An electronic survey, designed to capture both quantitative and qualitative data, was piloted and then circulated to members of the Association of Coloproctology of Great Britain and Ireland.

RESULTS

Two hundred and forty-two responses were received from 848 recipients (a 29% response rate) covering 104 of 135 (77%) acute NHS Trusts in England. EGS surgeons were in post in 43/141 (30%) hospitals overall and 12/24 (50%) of hospitals in London. Most respondents working in units with EGS surgeons found them to be advantageous (46/63, 73%). Consultants working with EGS surgeons were significantly more likely to support their use (49/63, 78%) than those without them (83/178, 47%) (χ²  = 16.9, P < 0.001). EGS surgeons were considered to improve the delivery of EGS (78%), create time for subspecialists (70%) and provide service (73%). However, there were concerns about the quality of surgery (43%), an insufficient standard of specialist care (54%) and compromise in the training of juniors (25%). Respondents commented on a lack of job structure with a high attrition rate (21%), the insufficient quality of applicants (18%) and that subspecialization and split on-call was preferable (17%).

CONCLUSION

Respondents were supportive of the ability of EGS surgeons to relieve pressure on subspecialists; however, there were significant concerns about the sustainability and quality of the EGS surgeon role. Emergency colorectal resections should have the input of a surgeon who performs elective colorectal resections.

National prospective cohort study of the burden of acute small bowel obstruction

Background

Small bowel obstruction is a common surgical emergency, and is associated with high levels of morbidity and mortality across the world. The literature provides little information on the conservatively managed group. The aim of this study was to describe the burden of small bowel obstruction in the UK.

Methods

This prospective cohort study was conducted in 131 acute hospitals in the UK between January and April 2017, delivered by trainee research collaboratives. Adult patients with a diagnosis of mechanical small bowel obstruction were included. The primary outcome was in‐hospital mortality. Secondary outcomes included complications, unplanned intensive care admission and readmission within 30 days of discharge. Practice measures, including use of radiological investigations, water soluble contrast, operative and nutritional interventions, were collected.

Results

Of 2341 patients identified, 693 (29·6 per cent) underwent immediate surgery (within 24 h of admission), 500 (21·4 per cent) had delayed surgery after initial conservative management, and 1148 (49·0 per cent) were managed non‐operatively. The mortality rate was 6·6 per cent (6·4 per cent for non‐operative management, 6·8 per cent for immediate surgery, 6·8 per cent for delayed surgery; P = 0·911). The major complication rate was 14·4 per cent overall, affecting 19·0 per cent in the immediate surgery, 23·6 per cent in the delayed surgery and 7·7 per cent in the non‐operative management groups (P < 0·001). Cox regression found hernia or malignant aetiology and malnutrition to be associated with higher rates of death. Malignant aetiology, operative intervention, acute kidney injury and malnutrition were associated with increased risk of major complication.

Conclusion

Small bowel obstruction represents a significant healthcare burden. Patient‐level factors such as timing of surgery, acute kidney injury and nutritional status are factors that might be modified to improve outcomes.

Laparoscopic versus open adhesiolysis for adhesive small bowel obstruction (LASSO): an international, multicentre, randomised, open-label trial

BACKGROUND

Although laparoscopic adhesiolysis for adhesive small bowel obstruction is being done more frequently, it is not widely accepted due to the lack of supporting evidence of its superiority over an open approach and concerns regarding its benefits. We aimed to investigate whether laparoscopic adhesiolysis was a superior treatment for adhesive small bowel obstruction compared with an open approach in terms of length of postoperative hospital stay and morbidity.

METHODS

In this international, multicentre, parallel, open-label trial, we randomly assigned patients (1:1) aged 18-95 years who had adhesive small bowel obstruction that had not resolved with conservative management to have either open or laparoscopic adhesiolysis. The study was done in five academic university hospitals and three community (central) hospitals in two countries (Finland [n=3 academic university hospitals; n=3 community hospitals] and Italy [n=2 academic university hospitals]). We included only patients with high likelihood of a single adhesive band in the trial; additionally, patients who had an anaesthesiological contraindication, were pregnant, living in institutionalised care, or who had a hospital stay of more than 1 week before the surgical consultation were excluded from the trial. The randomisation sequence was generated using block randomisation, with randomly varied block sizes and stratified according to centre. The primary outcome was postoperative length of hospital stay assessed at time of discharge in the modified intention-to-treat population.

FINDINGS

Between July 18, 2013, and April 9, 2018, 566 patients were assessed for eligibility, of whom 104 patients were randomly assigned to the open surgery group (n=51) or to the laparoscopy group (n=53). Of these patients, 100 were included in the modified intention-to-treat analyses (49 in the open surgery group; 51 in the laparoscopy group). The postoperative length of hospital stay for open surgery group was on average 1·3 days longer than that in the laparoscopy group (geometric mean 5·5 days [range 2-19] vs 4·2 days [range 1 -20]; ratio of geometric means 1·31 [95% CI 1·06-1·61]; p=0·013). 21 (43%) patients in the open surgery group and 16 (31%) patients in the laparoscopy group had postoperative complications (Clavien-Dindo any grade) within 30 days (odds ratio 0·61 [95% CI 0·27-1·38]; p=0·23). One patient died in each group within 30 days.

INTERPRETATION

Laparoscopic adhesiolysis provides quicker recovery in selected patients with adhesive small bowel obstruction than open adhesiolysis.

FUNDING

Vatsatautien Tutkimussäätiö Foundation, Mary and Georg Ehrnrooth's Foundation, Martti I Turunen Foundation, and governmental (Finland) competitive research funds (EVO/VTR/TYH).

Only Surgical Treatment to Be Considered for Adhesive Small Bowel Obstruction: A New Paradigm

Background

Adhesive small bowel obstruction (SBO) represents a heavy burden in healthcare systems worldwide and is associated with significant morbidity and mortality. Although conservative treatment alone can lead to SBO resolution in most cases, its optimal duration is still a matter of debate. The aim of this study was to analyze different SBO evolution patterns in order to further determine when to switch to surgical treatment.

Study Design

All patients who were admitted for adhesive SBO between 2011 and 2016 were reviewed. Patients who had immediate surgery (IS), a successful medical treatment (SMT), and a failed medical treatment (FMT) were compared in terms of overall morbidity, mortality, and SBO recurrence.

Results

Overall 154 patients were identified, including 23 (14.9%) in IS, 27 (17.5%) in FMT, and 104 (67.6%) in SMT groups. In terms of comorbidities, patients were similar in all groups. Overall morbidity rates were highest in IS and FMT groups (30% and 33%, respectively, vs. 4% in the SMT group, p < 0.001) whereas mortality rate was highest in the FMT group (22% vs. 0% and 0% in IS and SMT groups, respectively, p < 0.001). SBO recurrence rate was highest in the SMT group (22% vs. 4% and 7% in IS and FMT groups, respectively, p = 0.042).

Conclusion

FMT seems to be associated with similar overall morbidity compared with IS but with increased postoperative mortality. Patient frailty seems to be worsened by prolonged inefficient medical treatment.