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Tyagunov AE, Alieva ZM, Tyagunov AA, Nechai TV, Tsulaya AZ, Yusufov MP, Polushkin VG, Sazhin AV, Mirzoyan AT, Glagolev NS, Tavadov AV, Makhuova GB, Sazhin IV, Stradymov EA, Kurashinova LS, Lebedev IS. [Comparison of early operative treatment and 48-hour conservative treatment in small bowel obstruction (COTACSO): intermediate results]. Khirurgiia (Mosk) 2024:16-24. [PMID: 39008694 DOI: 10.17116/hirurgia202407116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
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.
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Affiliation(s)
- A E Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia
- Moscow Multi-Field Clinical Center «Kommunarka», Moscow, Russia
| | - Z M Alieva
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - T V Nechai
- Pirogov Russian National Research Medical University, Moscow, Russia
- Pirogov Moscow City Clinical Hospital No.1, Moscow, Russia
| | - A Z Tsulaya
- Buyanov Moscow City Clinical Hospital, Moscow, Russia
| | - M P Yusufov
- Buyanov Moscow City Clinical Hospital, Moscow, Russia
| | | | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
- Moscow Multi-Field Clinical Center «Kommunarka», Moscow, Russia
| | - A T Mirzoyan
- Pirogov Russian National Research Medical University, Moscow, Russia
- Moscow Multi-Field Clinical Center «Kommunarka», Moscow, Russia
| | - N S Glagolev
- Pirogov Russian National Research Medical University, Moscow, Russia
- BaumanMoscow City Hospital No. 29, Moscow, Russia
| | - A V Tavadov
- Moscow Multi-Field Clinical Center «Kommunarka», Moscow, Russia
| | - G B Makhuova
- Pirogov Russian National Research Medical University, Moscow, Russia
- Buyanov Moscow City Clinical Hospital, Moscow, Russia
| | - I V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
- Buyanov Moscow City Clinical Hospital, Moscow, Russia
| | - E A Stradymov
- Pirogov Russian National Research Medical University, Moscow, Russia
- Moscow Multi-Field Clinical Center «Kommunarka», Moscow, Russia
| | - L S Kurashinova
- Moscow Multi-Field Clinical Center «Kommunarka», Moscow, Russia
| | - I S Lebedev
- Pirogov Russian National Research Medical University, Moscow, Russia
- Moscow Multi-Field Clinical Center «Kommunarka», Moscow, Russia
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Girón F, Chaves CER, Rodríguez L, Rueda-Esteban RJ, Núñez-Rocha RE, Pedraza JD, Conde D, Vanegas M, Nassar R, Herrera G, Hernández JD. Association between clinical and surgical variables with postoperative outcomes in patients treated for intestinal obstruction for non-malignant conditions: a cross-sectional study. Sci Rep 2023; 13:14544. [PMID: 37666937 PMCID: PMC10477176 DOI: 10.1038/s41598-023-41328-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/24/2023] [Indexed: 09/06/2023] Open
Abstract
Intestinal obstruction is considered a frequent surgical pathology related to previous surgical procedures. Many different factors can lead to different outcomes when surgical management is needed. Therefore, we aim to describe the factors related to morbidity and mortality in surgical management of IO in a single-center experience. Retrospective observational study with a prospective database, in which we described patients who underwent surgical management due to intestinal obstruction between 2004 and 2015. Demographics, perioperative data, surgical outcomes, morbidity, and mortality were described. 366 patients were included. Female were 54.6%. Mean age was 61.26. Laparoscopic approach was done in 21.8% and the conversion rate was 17.2%. Intestinal resection was performed in 37.9% of the cases. Postoperative complications were observed in 18.85%. Reintervention and mortality were 9.5% and 4.1% respectively. Laparoscopic approach shows lesser time of intestinal transit (mean 28.67 vs. mean 41.95 h), and restart of oral intake after surgery (mean 96.06 vs. mean 119.65) compared with open approach. Increased heart rate and intensive care unit length of stay were related with mortality (p 0.01 and 0.000 respectively). For morbidity, laparotomy and need and duration of ICU stay were related with any complication statistically significant (p 0.02, 0.008, 0.000 respectively). Patients with increased heart rate in the emergency room, decreased amount of intravenous fluids, need and higher length of stay in the intensive care unit, and delay in resuming oral intake after surgery appear to have poor outcomes. Laparoscopic approach seems to be a safe and feasible approach for intestinal obstruction in selected patients.
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Affiliation(s)
- Felipe Girón
- Department of Surgery, Fundación Santa Fé de Bogotá, Carrera 7 # 117 - 15, 111711, Bogotá, D.C, Colombia.
- School of Medicine, Universidad del Rosario, 111711, Bogotá D.C, Colombia.
- School of Medicine, Universidad de los Andes, 111711, Bogotá D.C, Colombia.
| | | | - Lina Rodríguez
- School of Medicine, Universidad de los Andes, 111711, Bogotá D.C, Colombia
| | | | | | | | - Danny Conde
- School of Medicine, Universidad del Rosario, 111711, Bogotá D.C, Colombia
| | - Marco Vanegas
- School of Medicine, Universidad del Rosario, 111711, Bogotá D.C, Colombia
| | - Ricardo Nassar
- Department of Surgery, Fundación Santa Fé de Bogotá, Carrera 7 # 117 - 15, 111711, Bogotá, D.C, Colombia
- School of Medicine, Universidad del Rosario, 111711, Bogotá D.C, Colombia
- School of Medicine, Universidad de los Andes, 111711, Bogotá D.C, Colombia
| | - Gabriel Herrera
- Department of Surgery, Fundación Santa Fé de Bogotá, Carrera 7 # 117 - 15, 111711, Bogotá, D.C, Colombia
- School of Medicine, Universidad de los Andes, 111711, Bogotá D.C, Colombia
| | - Juan David Hernández
- Department of Surgery, Fundación Santa Fé de Bogotá, Carrera 7 # 117 - 15, 111711, Bogotá, D.C, Colombia
- School of Medicine, Universidad de los Andes, 111711, Bogotá D.C, Colombia
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Wassmer CH, Revol R, Uhe I, Chevallay M, Toso C, Gervaz P, Morel P, Poletti PA, Platon A, Ris F, Schwenter F, Perneger T, Meier RP. A new clinical severity score for the management of acute small bowel obstruction in predicting bowel ischemia: a cohort study. Int J Surg 2023; 109:1620-1628. [PMID: 37026805 PMCID: PMC10389338 DOI: 10.1097/js9.0000000000000171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/28/2022] [Indexed: 04/08/2023]
Abstract
BACKGROUND Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a nonviable small bowel remains a challenge. Through a prospective cohort study, the authors aimed to validate risk factors and scores for intestinal resection, and to develop a practical clinical score designed to guide surgical versus conservative management. PATIENTS AND METHODS All patients admitted for an acute SBO between 2004 and 2016 in the center were included. Patients were divided in three categories depending on the management: conservative, surgical with bowel resection, and surgical without bowel resection. The outcome variable was small bowel necrosis. Logistic regression models were used to identify the best predictors. RESULTS Seven hundred and thirteen patients were included in this study, 492 in the development cohort and 221 in the validation cohort. Sixty-seven percent had surgery, of which 21% had small bowel resection. Thirty-three percent were treated conservatively. Eight variables were identified with a strong association with small bowel resection: age 70 years of age and above, first episode of SBO, no bowel movement for greater than or equal to 3 days, abdominal guarding, C-reactive protein greater than or equal to 50, and three abdominal computer tomography scanner signs: small bowel transition point, lack of small bowel contrast enhancement, and the presence of greater than 500 ml of intra-abdominal fluid. Sensitivity and specificity of this score were 65 and 88%, respectively, and the area under the curve was 0.84 (95% CI: 0.80-0.89). CONCLUSION The authors developed and validated a practical clinical severity score designed to tailor management of patients presenting with an SBO.
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Affiliation(s)
| | - Rebecca Revol
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Isabelle Uhe
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Mickaël Chevallay
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Christian Toso
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Pascal Gervaz
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Philippe Morel
- Department of Surgery, University Hospitals of Geneva and Medical School
| | | | | | - Frederic Ris
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Frank Schwenter
- Department of Surgery, Montreal University Hospital CHUM, Université de Montréal, Montréal, Quebec, Canada
| | - Thomas Perneger
- Division of Clinical Epidemiology, Faculty of Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
| | - Raphael P.H. Meier
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Gilja OH, Nylund K. Point-of-care Ultrasound of the Gastrointestinal Tract. J Med Ultrasound 2023; 31:1-7. [PMID: 37180631 PMCID: PMC10173834 DOI: 10.4103/jmu.jmu_5_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 05/16/2023] Open
Abstract
The widespread use of portable ultrasound scanners has promoted the concept of point of care ultrasound (POCUS), namely "ultrasound performed bedside and interpreted directly by the clinician." The purpose of this short review is to outline how POCUS can be used in patients with diseases of the gastrointestinal (GI) tract. POCUS is not a replacement for comprehensive ultrasound, but rather allows physicians immediate access to clinical imaging for rapid diagnosis and efficient work-up and treatment of the patients. There are many indications for doing POCUS of the GI tract, including abdominal pain, diarrhea, palpable masses, and to detect fluid or free air in the abdominal cavity. To improve the visibility of deeper parts of the abdomen, the graded compression technique with the scan head is useful. During POCUS, the operator should look for signs of severe pathology including target lesions, the pseudo-kidney sign, the onion sign, dilated bowel loops, gastric retention, free fluid, and free air, depending on the actual clinical problem. We conclude that POCUS of the GI tract is very useful to provide a rapid diagnosis in many clinical scenarios.
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Affiliation(s)
- Odd Helge Gilja
- Department of Medicine, National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Address for correspondence: Prof. Odd Helge Gilja, Department of Medicine, National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, 5021 Bergen, Norway. E-mail:
| | - Kim Nylund
- Department of Medicine, National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Fruauff A, Trepanier C, Shaish H, Luk L. Delays in imaging diagnosis of acute abdominal pain in the emergency setting. Clin Imaging 2022; 90:32-38. [DOI: 10.1016/j.clinimag.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/09/2022] [Accepted: 06/26/2022] [Indexed: 11/28/2022]
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Tyagunov AE, Sazhin AV, Tyagunov AA, Nechay TV, Ermakov IV. [Preoperative diagnosis of intestinal ischemia in small bowel obstruction. Only computed tomography? A multiple-center observational study]. Khirurgiia (Mosk) 2022:26-35. [PMID: 36562670 DOI: 10.17116/hirurgia202212226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the accuracy of clinical, laboratory and instrumental methods for diagnosis of intestinal ischemia following small bowel obstruction in emergency hospitals. MATERIAL AND METHODS Multiple-center observational retrospective study enrolled 158 consecutive patients with benign small bowel obstruction (SBO) treated at four hospitals between May 2017 and December 2019. The role of clinical, laboratory and instrumental diagnostic methods for intestinal ischemia was analyzed. We assessed the impact of CT and contrast-enhanced X-ray examination on survival of patients. RESULTS Laboratory parameters as criteria of ischemia following SBO were similar (leukocytosis >14·109/l (p=1.0), serum lactate >2.0 mmol/l (p=0.28), heart rate >90/min (p=0.71) and fever (p=0.74)). The only laboratory indicator with significant differences was serum sodium. Decrease in leukocytosis over time was less common in patients with ischemia (25% vs. 61.3%, p=0.012). Univariate Kaplan-Meier analysis did not establish the effect of CT on survival (7.8% [95% CI 7.6-8.0] vs. 6.5% [95% CI 6.3-6.6], p=0.786). Logistic regression revealed 6.4-fold higher chance of accurate diagnosis (ischemia/non-ischemia) in case of CT-based conclusion of ischemia (95% CI 0.025-0.85). Univariate analysis showed that the use of water-soluble contrast for adhesive SBO was associated with lower mortality (4.1% [95% CI 4.0-4.2] vs. 14.3% [95% CI 13.7-14.9], p=0.032) without assessing the comparability of groups. CONCLUSION Routine laboratory tests were not specific for intestinal ischemia. Therefore, they should not be considered as the only criteria for surgical tactics in intestinal obstruction. Only CT showed acceptable diagnostic accuracy, and, apparently, only this method has real prospects for improving the quality of diagnosis due to technical support, training of surgeons and specialists for diagnosis.
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Affiliation(s)
- A E Tyagunov
- Moscow Multidisciplinary Clinical Center "Kommunarka", Moscow, Russia
| | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Tyagunov
- Buyanov Municipal Clinical Hospital No. 12, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I V Ermakov
- Pirogov Russian National Research Medical University, Moscow, Russia
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7
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Müller MH. Mechanische Obstruktion, paralytischer Ileus, postoperativer Ileus, Ileuskrankheit. SPRINGER REFERENCE MEDIZIN 2022:1-10. [DOI: 10.1007/978-3-662-61724-3_59-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 09/02/2023]
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Surgical treatment of mechanical bowel obstruction: characteristics and outcomes of geriatric patients compared to a younger cohort. Int J Colorectal Dis 2022; 37:1281-1288. [PMID: 35513540 PMCID: PMC9167188 DOI: 10.1007/s00384-022-04152-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Mechanical bowel obstruction (MBO) is one of the most common indications for emergency surgery. Recent research justifies the method of attempting 3-5 days of nonoperative treatment before surgery. However, little is known about specific characteristics of geriatric patients undergoing surgery compared to a younger cohort. We aimed to analyze patients with MBO that required surgery, depending on their age, to identify potential targets for use in the reduction in complications and mortality in the elderly. METHODS Thirty-day and in-hospital mortality were determined as primary outcome. We retrospectively identified all patients who underwent surgery for MBO at the University Hospital of Bonn between 2009 and 2019 and divided them into non-geriatric (40-74 years, n = 224) and geriatric (≥ 75 years, n = 88) patients, using the chi-squared-test and Mann-Whitney U test for statistical analysis. RESULTS We found that geriatric patients had higher 30-day and in-hospital mortality rates than non-geriatric patients. As secondary outcome, we found that they experienced a longer length of stay (LOS) and higher complication rates than non-geriatric patients. Geriatric patients who suffered from large bowel obstruction (LBO) had a higher rate of bowel resection, stoma creation, and a higher 30-day mortality rate. The time from admission to surgery was not shown to be crucial for the outcome of (geriatric) patients. CONCLUSION Geriatric patients suffering from mechanical bowel obstruction that had to undergo surgery had higher mortality and morbidity than non-geriatric patients. Especially in regard to geriatric patients, clinicians should treat patients in a risk-adapted rather than time-adapted manner, and conditions should be optimized before surgery.
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Guerrini J, Zugna D, Poretti D, Samà L, Costa G, Mei S, Ceolin M, Biloslavo A, Zago M, Viganò L, Kurihara H. Adhesive small bowel obstruction: Single band or matted adhesions? A predictive model based on computed tomography scan. J Trauma Acute Care Surg 2021; 90:917-923. [PMID: 33797496 DOI: 10.1097/ta.0000000000003182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Preoperative identification of the cause of adhesive small bowel obstruction (ASBO) is crucial for decision making. Some computed tomography (CT) findings can be indicative of single adhesive bands or matted adhesions. Our aim was to build a predictive model based on CT data to discriminate ASBO due to single adhesive band or matted adhesions. METHODS A retrospective single center study was conducted, covering all consecutive patients with a preoperative CT scan, undergoing urgent surgery for ASBO between January 1, 2005, and December 31, 2017. Preoperative CT scans were blindly reviewed, and all the CT findings indicative of single adhesive band or matted adhesions described in literature were recorded. According to intraoperative findings, ASBOs were retrospectively classified into single band and matted ASBO. All observed CT findings were compared between the two groups. A predictive model based on logistic regression was developed, and its ability was quantified by discrimination and calibration. Internal cross-validation was conducted by bootstrap resampling. RESULTS A total of 116 patients were analyzed (males, 53.5%; median age, 68 years; single band ASBO in 65.5% of cases). The odds of single band ASBO were increased four times in presence of complete obstruction (odds ratios, 4.19; 95% confidence interval, 1.49-12.56) and seven times in presence of fat notch sign (odds ratios, 7.37; 95% confidence interval, 1.83-40.03). The predictive model combining all CT findings had an accuracy of 86% in single band ASBO prediction. Accuracy decreased to 79% in the internal validation. Sensitivity, specificity, and positive and negative predictive values were calculated at different cut-points of the predicted risk: using a 0.70 cut-point, the specificity is 80%, the sensitivity is 68%, and the positive and negative predictive values are 87% and 57%, respectively. CONCLUSION The proposed predictive model based on combination of specific CT findings may elucidate whether ASBO is caused by single bands or matted adhesions and, consequently, influence the clinical pathway. LEVEL OF EVIDENCE Prognostic study, level IV.
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Affiliation(s)
- Jacopo Guerrini
- From the Humanitas Clinical and Research Center, IRCCS (J.G., D.P., S.M., M.C., H.K.), Rozzano, Milan; Department of Medical Sciences (D.Z.), University of Turin, Turin; Department of Biomedical Sciences (L.S., G.C., L.V.), Humanitas University, Pieve Emanuele, Milan; Azienda Ospedaliero-Universitaria "Ospedali Riuniti" (A.B.), Trieste; and Azienda Socio Sanitaria Territoriale (M.Z.), Lecco, Italy
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Hollerweger A, Maconi G, Ripolles T, Nylund K, Higginson A, Serra C, Dietrich CF, Dirks K, Gilja OH. Gastrointestinal Ultrasound (GIUS) in Intestinal Emergencies - An EFSUMB Position Paper. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2020; 41:646-657. [PMID: 32311749 DOI: 10.1055/a-1147-1295] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
An interdisciplinary group of European experts summarizes the value of gastrointestinal ultrasound (GIUS) in the management of three time-critical causes of acute abdomen: bowel obstruction, gastrointestinal perforation and acute ischemic bowel disease. Based on an extensive literature review, statements for a targeted diagnostic strategy in these intestinal emergencies are presented. GIUS is best established in case of small bowel obstruction. Metanalyses and prospective studies showed a sensitivity and specificity comparable to that of computed tomography (CT) and superior to plain X-ray. GIUS may save time and radiation exposure and has the advantage of displaying bowel function directly. Gastrointestinal perforation is more challenging for less experienced investigators. Although GIUS in experienced hands has a relatively high sensitivity to establish a correct diagnosis, CT is the most sensitive method in this situation. The spectrum of intestinal ischemia ranges from self-limited ischemic colitis to fatal intestinal infarction. In acute arterial mesenteric ischemia, GIUS may provide information, but prompt CT angiography is the gold standard. On the other end of the spectrum, ischemic colitis shows typical ultrasound features that allow correct diagnosis. GIUS here has a diagnostic performance similar to CT and helps to differentiate mild from severe ischemic colitis.
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Affiliation(s)
- Alois Hollerweger
- Department of Radiology, Hospital Barmherzige Brüder, Salzburg, Austria
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, "L.Sacco" University Hospital, Milan, Italy
| | - Tomas Ripolles
- Department of Radiology, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Kim Nylund
- Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Antony Higginson
- Department of Radiology, Queen-Alexandra-Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom of Great Britain and Northern Ireland
| | - Carla Serra
- Internal Medicine and Gastroenterology, S. Orsola University Hospital, Bologna, Italy
| | - Christoph F Dietrich
- Department of General Internal Medicine Kliniken Hirslanden Beau-Site, Salem und Permanence, Bern, Switzerland
| | - Klaus Dirks
- Gastroenterology and Internal Medicine, Rems-Murr-Klinikum Winnenden, Germany
| | - Odd Helge Gilja
- Haukeland University Hospital, National Centre for Ultrasound in Gastroenterology, Bergen, Norway
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11
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Thornblade LW, Verdial FC, Bartek MA, Flum DR, Davidson GH. The Safety of Expectant Management for Adhesive Small Bowel Obstruction: A Systematic Review. J Gastrointest Surg 2019; 23:846-859. [PMID: 30788717 PMCID: PMC6988581 DOI: 10.1007/s11605-018-4017-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/18/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical training has long been to "never let the sun set on a bowel obstruction" without an operation to rule out and/or treat compromised bowel. However, advances in diagnostics have called into question the appropriate timing of non-emergent operations and expectant management is increasingly used. We performed a systematic review to evaluate the safety and effectiveness of expectant management for adhesive small bowel obstruction (aSBO) compared to early, non-emergent operation. MATERIALS & METHODS We queried PubMed, EMBASE, and Cochrane databases for studies (1990-present) comparing early, non-emergent operations and expectant management for aSBO (PROSPERO #CRD42017057676). RESULTS Of 4873 studies, 29 cohort studies were included for full-text review. Four studies directly compared early surgery with expectant management, but none excluded patients who underwent emergent operations from those having early non-emergent surgery, precluding a direct comparison of the two treatment types of interest. When aggregated, the rate of bowel resection was 29% in patients undergoing early operation vs. 10% in those undergoing expectant management. The rate of successful, non-operative management in the expectant group was 58%. There was a 1.3-day difference in LOS favoring expectant management (LOS 9.7 vs. 8.4 days), and the rate of death was 2% in both groups. CONCLUSION Despite the shift towards expectant management of aSBO, no published studies have yet compared early, non-emergent operation and expectant management. A major limitation in evaluating the outcomes of these approaches using existing studies is confounding by indication related to including patients with emergent indications for surgery on admission in the early operative group. A future study, randomizing patients to early non-emergent surgery or expectant management, should inform the comparative safety and value of these approaches.
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Affiliation(s)
- Lucas W Thornblade
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
| | - Francys C Verdial
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
| | - Matthew A Bartek
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA.
| | - David R Flum
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
| | - Giana H Davidson
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, 1107 NE 45th Street, Suite 502, Seattle, WA, 98105, USA
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12
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Vilz TO, Stoffels B, Strassburg C, Schild HH, Kalff JC. Ileus in Adults. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:508-518. [PMID: 28818187 DOI: 10.3238/arztebl.2017.0508] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 11/21/2016] [Accepted: 02/28/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Ileus is one of the more common suspected diagnoses in everyday clinical practice. The term can refer either to mechanical or to functional ileus. Any physician who takes care of patients can be confronted with these entities; thus, all should be familiar with them and competent in their management. METHODS Recommendations are summarized for the diagnostic evaluation and treatment of ileus of various causes on the basis of a selective literature review. RESULTS The manifestations of ileus and its degree of severity generally depend on the site of blockage. The rule until recently was that a patient with suspected mechanical ileus should be taken to surgery within 12 hours; today, however, ileus-particularly of the small bowel-can often be successfully treated conservatively. Likewise, functional ileus only rarely requires surgery: supportive measures, depending on the etiology, usually suffice. CONCLUSION Proper treatment depends on the timely determination of the pathogenesis (mechanical versus functional) and on close interdisciplinary collaboration. A special challenge is posed by patients with peritoneal involvement with cancer who present with symptoms of ileus, in whom a clear distinction between mechanical and functional causation cannot always be drawn.
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Affiliation(s)
- Tim O Vilz
- Department of General, Visceral-, Thoracic and Vascular Surgery, Bonn University Hospital; Department of Internal Medicine I, Bonn University Hospital; Department of Radiology, Bonn University Hospital
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Evolving Management Strategies in Patients with Adhesive Small Bowel Obstruction: a Population-Based Analysis. J Gastrointest Surg 2018; 22:2133-2141. [PMID: 30051307 DOI: 10.1007/s11605-018-3881-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/10/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND In patients with adhesive small bowel obstruction (aSBO), the decision to operate as well as the timing and technique of surgery have significant impacts on clinical outcomes. Trends in the management of aSBO have not been described at the population level and guideline adherence is unknown. We sought to evaluate the secular trends in the management of aSBO in a large North American population. METHODS We used administrative data to identify patients admitted to hospital for their first episode of aSBO over 2005-2014. We evaluated temporal trends in admission for aSBO and in management practices using Cochran-Armitage tests. Multivariable logistic regressions were used to assess trends when controlling for potential confounders. RESULTS Patients (40,800) were admitted with their first episode of aSBO. The mean age was 68.5 years and 55% of patients were female. The population-based rate of admission for aSBO decreased over the study period, from 39.1 to 38.1 per 100,000 persons per year. There was a significant increase in the proportion of patients who underwent surgery for aSBO (19 to 23%, p < 0.0001). Among those who underwent surgery, there were significant increases in the proportions of patients who underwent laparoscopic procedures (4 to 14%, p < 0.0001) and who underwent surgery within 1 day of admission (51 to 60%, p < 0.0001). CONCLUSION Between 2005 and 2014, there was a decrease in the population-based rate of aSBO, which may reflect increased utilization of minimally invasive techniques. There were significant trends towards increased operative intervention, with surgery occurring earlier and increasingly using laparoscopic approach.
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14
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Bower KL, Lollar DI, Williams SL, Adkins FC, Luyimbazi DT, Bower CE. Small Bowel Obstruction. Surg Clin North Am 2018; 98:945-971. [PMID: 30243455 DOI: 10.1016/j.suc.2018.05.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Katie Love Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA.
| | - Daniel I Lollar
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Sharon L Williams
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Farrell C Adkins
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - David T Luyimbazi
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Curtis E Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
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Oldani A, Gentile V, Magaton C, Calabrò M, Maroso F, Ravizzini L, Deiro G, Amato M, Gentilli S. Emergency surgery for bowel obstruction in extremely aged patients. MINERVA CHIR 2018; 75:11-14. [PMID: 29658678 DOI: 10.23736/s0026-4733.18.07713-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND As a result of the increasing of life expectancy, the incidence of pathologies that can lead to operation for bowel obstruction is also increasing. Comorbidities and reduced physiological reserve can decrease elderly patients' ability to tolerate operations especially in an emergency context. We retrospectively evaluated the treatment and outcomes of a cohort of patients aged more than 85 years who underwent emergency surgery for intestinal occlusion. METHODS Two hundred seventy-eight patients who were admitted to our Institution and operated for acute bowel obstruction have been included in our study. We divided the study population in 2 groups (group A: patients aged>85 years old; group B patients aged ≤85 years). We evaluated the differences between the two groups in terms of intestinal occlusion aetiology, surgical procedures, morbidity and mortality rates. RESULTS Group A consisted of 57 patients, group B of 221; elderly patients trend in ASA score classification was significantly towards high risk for elderly group; statistical analysis did not show differences in terms of bowel obstruction etiology (except colon volvulus, more frequent in advanced age), type of procedure, duration of hospital stay, procedure-related complication rate. Perioperative mortality was significantly higher in elderly group, due to the mayor incidence of cardiovascular and respiratory fatal events directly related to pre-existing comorbidities. CONCLUSIONS Despite the high surgical risk, early diagnosis and treatment of the obstructive disease can lead to achieve encouraging outcomes also in extremely advanced age; an aggressive evaluation of comorbidities and the cardiorespiratory risks reduction, when possible, could be useful in improve postoperative outcomes in terms of mortality.
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Affiliation(s)
- Alberto Oldani
- Division of General Surgery, Department of Health Sciences, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy -
| | - Valentina Gentile
- Division of General Surgery, Department of Health Sciences, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Chiara Magaton
- Division of General Surgery, Department of Health Sciences, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Marcello Calabrò
- Division of General Surgery, Department of Health Sciences, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Fabio Maroso
- Division of General Surgery, Department of Health Sciences, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Lidia Ravizzini
- Division of General Surgery, Department of Health Sciences, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Giacomo Deiro
- Division of General Surgery, Department of Health Sciences, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Maurizio Amato
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Sergio Gentilli
- Division of General Surgery, Department of Health Sciences, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
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16
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Sazhin AV, Tyagunov AE, Larichev SE, Lebedev IS, Makhuova GB, Marchenko IP, Polushkin VG, Tyagunov AA, Sazhin IV, Nechay TV, Ivakhov GB, Titkova SM, Anurov MV, Gasanov MM, Kolygin AV, Mirzoyan AT, Glagolev NS, Kurashinova LS. [Optimal time of surgery for acute adhesive small bowel obstruction]. Khirurgiia (Mosk) 2018:24-30. [PMID: 29560955 DOI: 10.17116/hirurgia2018324-30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To define optimal terms of surgery for acute adhesive non-strangulatory small bowel obstruction. MATERIAL AND METHODS The analysis included 703 publications from e-LIBRARI.RU (342 works) and NCBI (361 works) databases for acute adhesive intestinal obstruction. The vast majority of articles presented retrospective analysis of single-center experience. RESULTS It has been established that short course of medication is predominantly used for acute adhesive intestinal obstruction in the Russian Federation. International studies point 2-5 days for conservative treatment. The advantages and disadvantages of short and long courses of medication were analyzed. Therefore, multicenter, prospective, randomized trial 'Comparison of early operative treatment (12-hour medication) and long-term conservative treatment (48 hours) for acute adhesive small bowel obstruction' (COTACSO) was planned and registered (Unique Protocol ID: 14121729). The study protocol involves clinical, laboratory and instrumental exclusion of strangulation, randomization and conservative treatment of 2 groups of patients for 12 and 48 hours. Patients will undergo surgical interventions if obstruction will be present by that date. The main endpoint is mortality rate in both groups. The end of the study is December 2020.
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Affiliation(s)
- A V Sazhin
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - A E Tyagunov
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia; Bauman Municipal Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - S E Larichev
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - I S Lebedev
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia; Pirogov Municipal Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - G B Makhuova
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia; Buyanov Municipal Clinical Hospital #12 of Moscow Healthcare Department, Moscow, Russia
| | - I P Marchenko
- Bauman Municipal Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - V G Polushkin
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - A A Tyagunov
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - I V Sazhin
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia; Buyanov Municipal Clinical Hospital #12 of Moscow Healthcare Department, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - G B Ivakhov
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - S M Titkova
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - M V Anurov
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - M M Gasanov
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - A V Kolygin
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia; Bauman Municipal Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - A T Mirzoyan
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia; Bauman Municipal Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - N S Glagolev
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia; Bauman Municipal Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - L S Kurashinova
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
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A Systematic Review of the Clinical Presentation, Diagnosis, and Treatment of Small Bowel Obstruction. Curr Gastroenterol Rep 2017; 19:28. [PMID: 28439845 DOI: 10.1007/s11894-017-0566-9] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy. RECENT FINDINGS SBO incidence is about 350,000/annum in the USA. Etiologies include adhesions (65%), hernias (10%), neoplasms (5%), Crohn's disease (5%), and other (15%). Bowel dilatation occurs proximal to obstruction primarily from swallowed air and secondarily from intraluminal fluid accumulation. Dilatation increases mural tension, decreases mucosal perfusion, causes bacterial proliferation, and decreases mural tensile strength that increases bowel perforation risks. Classical clinical tetrad is abdominal pain, nausea and emesis, abdominal distention, and constipation-to-obstipation. Physical exam may reveal restlessness, acute illness, and signs of dehydration and sepsis, including tachycardia, pyrexia, dry mucous membranes, hypotension/orthostasis, abdominal distention, and hypoactive bowel sounds. Severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness suggest advanced SBO, as do marked leukocytosis, neutrophilia, bandemia, and lactic acidosis. Differential diagnosis includes postoperative ileus, narcotic bowel, colonic pseudo-obstruction, mesenteric ischemia, and large bowel obstruction. Medical resuscitation includes intravenous hydration, correcting electrolyte abnormalities, intravenous antibiotics, nil per os, and nasoenteral suction. Abdominal CT with oral and intravenous gastrografin contrast is highly sensitive and specific in detecting/characterizing SBO. SBO usually resolves with medical therapy but requires surgery, preferentially by laparoscopy, for unremitting total obstruction, bowel perforation, severe ischemia, or clinical deterioration with medical therapy. Overall mortality is 10% but increases to 30% with bowel necrosis/perforation. Key point in SBO is early diagnosis, emphasizing abdominal CT; aggressive medical therapy including rehydration, antibiotics, and nil per os; and surgery for failed medical therapy.
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18
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Mazzetti CH, Serinaldi F, Lebrun E, Lemaitre J. Early laparoscopic adhesiolysis for small bowel obstruction: retrospective study of main advantages. Surg Endosc 2017; 32:2781-2792. [PMID: 29218668 DOI: 10.1007/s00464-017-5979-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/05/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND The problem of managing adhesional small bowel obstruction (ASBO) is still unsolved. A conservative medical attitude is privileged even if it is associated to a high rate of recurrences, while surgery is applied to cases showing no improvement after 48-72 h. Adhesiolysis via laparotomy has been the standard surgical management, but it causes other adhesions in a vicious circle. The aim of the study is to evaluate the advantages of early laparoscopic adhesiolysis as an alternative approach. METHODS From January 2010 to April 2017, 107 patients were admitted with a diagnosis of ASBO. Patients underwent medical treatment, early surgery, emergency surgery or delayed surgery after failure of medical treatment. A retrospective review and explorative statistical analysis were performed using graphical diagnostic plots, Mann-Whitney (MW) test, Kolmogorov-Smirnov (KS) test, exact binomial test, and χ 2 test. RESULTS Medical treatment led to resolution in the 77.3% of cases, but patients exhibit much more recurrences than those in the surgical group (χ 2 p < .001). They also show a longer fasting time (MW p = .027; KS p = .102), a doubled number of radiological exams (MW p < .001; KS p < .001), and more major complications than those in the early surgery group. Early surgery group is associated to shorter fasting time (MW p < .001; KS p < .001), much shorter hospital stay (MW p < .001; KS p = .002) and a smaller number of radiological exams (MW p = .005; KS p = .002) compared with delayed surgery group. The laparoscopic group shows significantly earlier regain of intestinal transit (MW p < .001; KS p = .002), shorter fasting time (MW p = .002; KS p = .008), reduced number of radiological exams (MW p = .003; KS p = .014), reduced hospital stay (MW p < .001; KS p = .005), and no more complications than the open surgery group. CONCLUSIONS Early laparoscopic surgery can be proposed as an effective alternative treatment for ASBO.
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Affiliation(s)
- Claudia Hannele Mazzetti
- Department of Visceral Surgery, Centre Hospitalier Universitaire Ambroise Pare, Bd Kennedy 2, 7000, Mons, Belgium.
| | - Francesco Serinaldi
- School of Engineering, Newcastle University, Newcastle Upon Tyne, UK.,Willis Research Network, London, UK
| | - Eric Lebrun
- Department of Visceral Surgery, Centre Hospitalier Universitaire Ambroise Pare, Bd Kennedy 2, 7000, Mons, Belgium
| | - Jean Lemaitre
- Department of Visceral Surgery, Centre Hospitalier Universitaire Ambroise Pare, Bd Kennedy 2, 7000, Mons, Belgium
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19
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Chang YJ, Yan DC, Lai JY, Chao HC, Chen CL, Chen SY, Tsai MH. Strangulated small bowel obstruction in children. J Pediatr Surg 2017; 52:1313-1317. [PMID: 28318600 DOI: 10.1016/j.jpedsurg.2017.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 03/05/2017] [Accepted: 03/07/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Diagnosing intestinal strangulation as a complication of small bowel obstruction (SBO) remains a considerable challenge in children. We evaluated the clinicoradiological parameters for predicting the presence of a strangulated intestine. METHODS We reviewed the medical records of 69 pediatric patients who underwent operation for acute SBO. Regression analysis was used to identify the parameters for predicting strangulated SBO. RESULTS Of the 69 patients with SBO, 27 patients had intestinal strangulation and were awarded one point each towards the overall clinical score: intractable continuous abdominal pain, tachycardia, white blood cell count >13,600/mm3, and abdominal distention. Patients with a clinical score ≥2 combined with the presence of ascites in ultrasound (US) results or with wall thickness and reduced wall contrast enhancement in abdominal computed tomography (CT) scans showed strong evidence for intestinal strangulation. CONCLUSION The combination of two or more clinical parameters, including intractable continuous abdominal pain, tachycardia, leukocytosis, and abdominal distention with the presence of ascites in US or wall thickness and reduced wall contrast enhancement in, is useful for the identification of strangulated SBO. THE TYPE OF STUDY AND LEVEL OF EVIDENCE Prognosis study; Level III.
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Affiliation(s)
- Yi-Jung Chang
- Department of Pediatrics, Chang Gung Children's Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Dah-Chin Yan
- Department of Pediatrics, Chang Gung Children's Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jin-Yao Lai
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Department of Pediatric Surgery, Chang Gung Children's Hospital, Taoyuan, Taiwan
| | - Hsun-Chin Chao
- Department of Pediatrics, Chang Gung Children's Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chyi-Liang Chen
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shih-Yen Chen
- Department of Pediatrics, Chang Gung Children's Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Han Tsai
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Pediatrics, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan.
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20
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Krause WR, Webb TP. Geriatric small bowel obstruction: an analysis of treatment and outcomes compared with a younger cohort. Am J Surg 2014; 209:347-51. [PMID: 25048569 DOI: 10.1016/j.amjsurg.2014.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 04/07/2014] [Accepted: 04/17/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Small bowel obstruction (SBO) is a common condition, but little is known about its presentation, management, and outcomes in geriatric patients. METHODS A retrospective review was performed comparing geriatric (≥65 years of age) and nongeriatric patients admitted with SBO. Admission characteristics, treatment, and outcomes were compared. Data analysis included Student t test and chi-square test or Fisher's exact test. RESULTS Among 80 geriatric and 136 nongeriatric patients, no difference was observed among admission characteristics, treatment, time to or type of surgery, length of postoperative stay, or overall complications. Cardiac complications (15% vs 0%, P = .0082) and subacute care facility discharge (29% vs 5%, P < .001) were more common for geriatric patients. CONCLUSIONS Compared with younger adults, elderly patients with SBO have similar presentations and overall outcomes with the exception of cardiac morbidity and discharge disposition. Preoperative attention to cardiac risk profile and discharge disposition discussion should be encouraged.
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Affiliation(s)
- William R Krause
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Travis P Webb
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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21
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Di Saverio S, Coccolini F, Galati M, Smerieri N, Biffl WL, Ansaloni L, Tugnoli G, Velmahos GC, Sartelli M, Bendinelli C, Fraga GP, Kelly MD, Moore FA, Mandalà V, Mandalà S, Masetti M, Jovine E, Pinna AD, Peitzman AB, Leppaniemi A, Sugarbaker PH, Goor HV, Moore EE, Jeekel J, Catena F. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg 2013; 8:42. [PMID: 24112637 PMCID: PMC4124851 DOI: 10.1186/1749-7922-8-42] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 09/23/2013] [Indexed: 12/19/2022] Open
Abstract
Background In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy. Recommendations In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay. NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended. Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery. Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained. Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery. Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.
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Affiliation(s)
- Salomone Di Saverio
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | | | - Marica Galati
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Nazareno Smerieri
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Walter L Biffl
- Department of Surgery, Denver Health, University of Colorado Health Sciences Denver, Denver Health Medical Center, 777 Bannock Street, Denver CO 80204, USA
| | - Luca Ansaloni
- General Surgery I, Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - Gregorio Tugnoli
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - George C Velmahos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Cino Bendinelli
- Department of Surgery, John Hunter Hospital and University of Newcastle, Locke Bag 1 Hunter Region Maile Centre, Newcastle, NSW 2310, Australia
| | | | - Michael D Kelly
- Upper GI Unit, Department of Surgery, Frenchay Hospital, North Bristol, NHS Trust, Bristol, UK
| | - Frederick A Moore
- Department of Surgery, University of Florida, Gainesville, FL 32610-0254, USA
| | - Vincenzo Mandalà
- Department of General and Emergency Surgery, Associated Hospitals "Villa Sofia - Cervello", Palermo, Italy
| | - Stefano Mandalà
- Department of General and Emergency Surgery, Associated Hospitals "Villa Sofia - Cervello", Palermo, Italy
| | - Michele Masetti
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Elio Jovine
- Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Antonio D Pinna
- Emergency Surgery Unit, Department of General and Multivisceral Transplant Surgery, S Orsola Malpighi University Hospital, Bologna, Italy
| | - Andrew B Peitzman
- Division of General Surgery, University of Pittsburgh Physicians, Pittsburgh 15213 PA, USA
| | - Ari Leppaniemi
- Emergency Surgery, Department of Abdominal Surgery, Meilahti Hospital, University of Helsinki, Haartmaninkatu 4, 340, Helsinki FIN-00029 HUS, Finland
| | - Paul H Sugarbaker
- Washington Cancer Institute, Washington Hospital Center, Washington, 20010 DC, USA
| | - Harry Van Goor
- Department of Surgery, Radboud University Nijmegen Medical Centre, P.O. Box 9101 6500 HB, Nijmegen, The Netherlands
| | - Ernest E Moore
- Department of Surgery, Denver Health, University of Colorado Health Sciences Denver, Denver Health Medical Center, 777 Bannock Street, Denver CO 80204, USA
| | - Johannes Jeekel
- Department of Surgery, Erasmus University Medical Center, PO Box 2040 3000 CA, Rotterdam, The Netherlands
| | - Fausto Catena
- Emergency Surgery Unit, Department of General and Multivisceral Transplant Surgery, S Orsola Malpighi University Hospital, Bologna, Italy.,Department of Emergency and Trauma Surgery, Maggiore Hospital of Parma, Parma, Italy
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