Surgery for acute abdominal conditions in intellectually-disabled adults

Cholelithiasis prevalence and risk factors in individuals with severe or profound intellectual and motor disabilities

BACKGROUND

The prevalence and risk factors of cholelithiasis in individuals with severe or profound intellectual and motor disabilities (SPIMD) are poorly characterised. Thus, we aimed to investigate the prevalence and risk determinants of cholelithiasis in a cohort with SPIMD under medical care in a residential facility.

METHODS

We categorised 84 patients in a residential hospital for persons with SPIMD into groups: those with (Group CL) and without (Group N) cholelithiasis. Gallstones were detected via computed tomography, ultrasonography or both. We evaluated gastrostomy status, nutritional and respiratory support, constipation, and bladder and kidney stones. Data were significantly analysed using univariate and multivariate logistic regression analyses.

RESULTS

The prevalence rate of cholelithiasis in our SPIMD cohort was 27%. There were no significant differences in sex, age, weight, height, or Gross Motor Function Classification System between the two groups. However, more patients received enteral nutrition (39.13% vs. 6.56%; P = 0.000751) and were on ventilator support (56.52% vs. 19.67%; P = 0.00249) in Group CL than in Group N. Enteral nutrition [odds ratio (OR) 10.4, 95% confidence interval (CI) 1.98-54.7] and ventilator support (OR 20.0, 95% CI 1.99-201.0) were identified as independent risk factors for the prevalence of cholelithiasis in patients with SPIMD.

CONCLUSIONS

Patients with SPIMD demonstrated an increased prevalence of cholelithiasis, with a notable association between nutritional tonic use and respiratory support. Therefore, to emphasise the need for proactive screening, it is crucial to devise diagnostic and therapeutic strategies specific to patients with SPIMD. Further investigation is essential to validate our findings and explore causative factors.

Surgery for acute abdomen in adult patients with severe motor and intellectual disabilities

Purpose

The present study aimed to examine the characteristics, outcomes, and problems related to surgery for acute abdomen in adult patients with severe motor and intellectual disabilities (MID).

Methods

The clinical records of 35 adult patients with severe MID who received emergency surgery for acute abdomen between 2011 and 2020 were reviewed.

Results

The median duration from onset to surgery was 48 hours. There were 2 cases of in-hospital mortality (5.7%), and all the patients underwent surgery more than 72 hours after onset. The in-hospital mortality rate was significantly higher in patients who received surgery later than 72 hours after onset. Bowel obstruction was the most common disease among the acute abdomen cases (71.4%) and most often involved volvulus of the small bowel and cecum. Of the patients with bowel obstruction with severe MID, 72.0% had abdominal distention, 16.0% had abdominal pain, and 4.0% had vomiting. The median duration from onset to surgery was significantly longer in the patients with bowel obstruction with severe MID than in those without severe MID (24 hours vs. 16 hours).

Conclusion

Acute abdomen in patients with severe MID was often due to bowel obstruction caused by volvulus. Because patients with severe MID have few symptoms, they are susceptible to adverse surgical outcomes associated with a prolonged duration from onset to surgery.

Complicated Appendicitis Among Adults With and Without Disabilities: A Cross-Sectional Nationwide Study in South Korea

Objective

Appendicitis is usually diagnosed based on a reliable set of signs and symptoms, and can be effectively treated with surgery, with low morbidity and mortality rates. However, appendicitis is often overlooked in vulnerable populations, including people with disabilities. This study compared 10-year trends of complicated appendicitis between South Koreans with a disability, according to disability severity and type, and those without disabilities

Methods

To identify cases of appendicitis, we used the DRG codes in the National Health Information Database of South Korea. Patients with appendicitis were classified in terms of severity based on the DRG codes. Age-standardized incidence rates were calculated for each year during 2008–2017 according to the presence, type, and severity of the disability. Factors associated with complicated appendicitis were examined by multivariate logistic regression using the most recent data (i.e., 2016–2017).

Results

The incidence of complicated appendicitis was higher in people with disabilities, especially those with severe disabilities (26.9 vs. 11.6%). This difference was particularly marked when considering those with a severe disability (aOR = 1.868, 95% CI:1.511–2.309), internal organ problems (aOR = 10.000, 95% CI:5.365–18.638) or a mental disability (aOR = 2.779, 95% CI:1.563–4.939).

Conclusions

The incidence of complicated appendicitis was higher in people with disability than in those without disability in all years. There was a substantial difference in the incidence of complicated appendicitis between the severe disability and non-disabled groups. Among the various disability types, the incidence of complicated appendicitis was highest for major internal organ problems, followed by intellectual or psychological disabilities. Our findings may be explained by barriers to healthcare access among people with disabilities, particularly those with a severe disability, internal organ problem, or mental disability.

Cecal volvulus complicated by evisceration case report

This case of bowel obstruction with multiple postoperative complications provides unique insight into the challenges faced by providers caring for intellectually disabled patients with acute surgical abdominal pathology and poor compliance. In this case, the component separation was utilized as a method of facilitated wound closure and compliance in a postoperative course highlighted by both dehiscence and wound infection. The patient, only able to communicate the presence of abdominal pain due to his disability, was surgically managed for a bowel obstruction secondary to a cecal volvulus. The difficulty in initial communication and patient noncompliance help illustrate the individualized care these patients require. This report will demonstrate both the challenges present in the management of intellectually disabled patients with abdominal wounds, as well as the use of component separation in providing both initial wound closure and continued wound integrity with the goal of reducing postoperative complications in patients with decreased compliance.

Recurrent cholecystitis in an elderly mentally retarded patient with pica

The case of a 64-year-old patient with pica and severe mental retardation who was admitted to our hospital for treatment of recurrent cholecystitis is reported. Abdominal ultrasound showed sludge in the gallbladder, but no stones. Abdominal CT revealed a foreign body in the duodenum resembling a suction cup of the type commonly used in kitchens and bathrooms. The object could not be removed because it was deeply embedded in the hypertrophic intestinal mucosa. A nasogastric tube was inserted for feeding, since the object impeded the passage of solid foods. The patient's fever and abdominal pain subsequently resolved, and laboratory data improved. The indwelling feeding tube prevented recurrence of cholecystitis. Since pica is common not only in patients with mental retardation but also in dementia patients, the present case may also relate to the treatment of acute abdominal conditions in dementia patients.

Postoperative adverse outcomes in intellectually disabled surgical patients: a nationwide population-based study

Background

Intellectually disabled patients have various comorbidities, but their risks of adverse surgical outcomes have not been examined. This study assesses pre-existing comorbidities, adjusted risks of postoperative major morbidities and mortality in intellectually disabled surgical patients.

Methods

A nationwide population-based study was conducted in patients who underwent inpatient major surgery in Taiwan between 2004 and 2007. Four controls for each patient were randomly selected from the National Health Insurance Research Database. Preoperative major comorbidities, postoperative major complications and 30-day in-hospital mortality were compared between patients with and without intellectual disability. Use of medical services also was analyzed. Adjusted odds ratios using multivariate logistic regression analyses with 95% confidence intervals were applied to verify intellectual disability's impact.

Results

Controls were compared with 3983 surgical patients with intellectual disability. Risks for postoperative major complications were increased in patients with intellectual disability, including acute renal failure (odds ratio 3.81, 95% confidence interval 2.28 to 6.37), pneumonia (odds ratio 2.01, 1.61 to 2.49), postoperative bleeding (odds ratio 1.35, 1.09 to 1.68) and septicemia (odds ratio 2.43, 1.85 to 3.21) without significant differences in overall mortality. Disability severity was positively correlated with postoperative septicemia risk. Medical service use was also significantly higher in surgical patients with intellectual disability.

Conclusion

Intellectual disability significantly increases the risk of overall major complications after major surgery. Our findings show a need for integrated and revised protocols for postoperative management to improve care for intellectually disabled surgical patients.