1
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Lin SW, Chen CY, Chen PC, Feng CL, Lin HY, Chen JH. Assessing risk of recurrent small bowel obstruction after non-operative management in patients with history of intra-abdominal surgery: a population-based comprehensive analysis in Taiwan. Surg Endosc 2024; 38:2433-2443. [PMID: 38453749 DOI: 10.1007/s00464-024-10746-6] [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: 08/26/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Despite a significant 30% ten-year readmission rate for SBO patients, investigations into recurrent risk factors after non-operative management are scarce. The study aims to generate a risk factor scoring system, the 'Small Bowel Obstruction Recurrence Score' (SBORS), predicting 6-month recurrence of small bowel obstruction (SBO) after successful non-surgical management in patients who have history of intra-abdominal surgery. METHODS We analyzed data from patients aged ≥ 18 with a history of intra-abdominal surgery and diagnosed with SBO (ICD-9 code: 560, 568) and were successful treated non-surgically between 2004 and 2008. Participants were divided into model-derivation (80%) and validation (20%) group. RESULTS We analyzed 23,901 patients and developed the SBORS based on factors including the length of hospital stay > 4 days, previous operations > once, hemiplegia, extra-abdominal and intra-abdominal malignancy, esophagogastric surgery and intestino-colonic surgery. Scores > 2 indicated higher rates and risks of recurrence within 6 months (12.96% vs. 7.27%, OR 1.898, p < 0.001 in model-derivation group, 12.60% vs. 7.05%, OR 1.901, p < 0.001 in validation group) with a significantly increased risk of mortality and operative events for recurrent episodes. The SBORS model demonstrated good calibration and acceptable discrimination, with an area under curve values of 0.607 and 0.599 for the score generation and validation group, respectively. CONCLUSIONS We established the effective 'SBORS' to predict 6-month SBO recurrence risk in patients who have history of intra-abdominal surgery and have been successfully managed non-surgically for the initial obstruction event. Those with scores > 2 face higher recurrence rates and operative risks after successful non-surgical management.
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Affiliation(s)
- Shang-Wei Lin
- Division of Plastic Surgery, Department of Surgery, Cathay General Hospital, Taipei, 10630, Taiwan
- Department of Surgery, Cathay General Hospital, Taipei, 10630, Taiwan
| | - Chung-Yen Chen
- Division of General Surgery, Department of Surgery, E-Da Hospital, Kaohsiung, Taiwan
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Pin-Chun Chen
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Colon & Rectal Surgery, Department of Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Che-Lun Feng
- Division of General Surgery, Department of Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Hung-Yu Lin
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
- Division of Urology, Department of Surgery, E-Da Cancer & E-Da Hospital, Kaohsiung, Taiwan.
| | - Jian-Han Chen
- Division of General Surgery, Department of Surgery, E-Da Hospital, Kaohsiung, Taiwan.
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan.
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
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2
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Richardson S, Chervu NL, Mabeza RM, Cho NY, Ng A, Verma A, Vadlakonda A, Bakhtiyar SS, Benharash P. Impact of delayed intervention following admission for small bowel obstruction: A contemporary analysis. Surg Open Sci 2023; 16:8-13. [PMID: 37744310 PMCID: PMC10514302 DOI: 10.1016/j.sopen.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/14/2023] [Accepted: 09/08/2023] [Indexed: 09/26/2023] Open
Abstract
Background The optimal timing of surgical intervention for small bowel obstruction (SBO) remains debated. Methods All adults admitted for SBO were identified in the 2018-2019 National Inpatient Sample. Patients undergoing small bowel resection or lysis of adhesion after three days were considered part of the Delayed cohort. All others were classified as Early. Multivariable regressions were used to assess independent predictors of delayed surgical intervention as well as associations between delayed management and in-hospital mortality, major adverse events (MAE), perioperative complications, postoperative length of stay (LOS), hospitalization costs and non-home discharge. Results Among 28,440 patients who met study criteria, 52.0 % underwent delayed intervention. Black race (AOR 1.19, 95 % CI 1.03-1.36, ref.: White) and Medicare coverage (AOR 1.16, 95 % CI 1.01-1.33, ref.: private payer) were associated with increased odds of delayed surgical management. While delayed intervention was not significantly associated with death (AOR 1.27, 95 % CI 0.97-1.68), it was linked to greater odds of MAE (AOR 1.30, 95 % CI 1.16-1.45) and several perioperative complications. The Delayed cohort also faced an incremental increase in postoperative LOS (+1.29 days, 95 % CI 0.89-1.70) and hospitalization costs (+$11,000, 95 % CI 10,000-12,000). Moreover, delayed intervention was linked to increased odds of non-home discharge (AOR 1.64, 95 % CI 1.47-1.84). Conclusions Delay in surgical management following SBO is linked to inferior clinical outcomes and increased resource use. Our findings highlight the need to ensure proper timing of surgery for SBO as well as efforts to standardize these practices across all demographics of patients.
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Affiliation(s)
- Shannon Richardson
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Nikhil L. Chervu
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Russyan Mark Mabeza
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Ayesha Ng
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado Aurora, CO, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
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3
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Maienza E, Godiris-Petit G, Noullet S, Menegaux F, Chereau N. Management of adhesive small bowel obstruction: the results of a large retrospective study. Int J Colorectal Dis 2023; 38:224. [PMID: 37668744 PMCID: PMC10480247 DOI: 10.1007/s00384-023-04512-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Postoperative adhesive small bowel obstruction (SBO) is a frequent cause of hospital admission in a surgical department. Emergency surgery is needed in a majority of patients with bowel ischemia or peritonitis; most adhesive SBO can be managed nonoperatively. Many studies have investigated benefits of using oral water-soluble contrast to manage adhesive SBO. Treatment recommendations are still controversial. METHODS We conducted an observational retrospective monocentric study to test our protocol of management of SBO using Gastrografin®, enrolling 661 patients from January 2008 to December 2021. An emergency surgery was performed in patients with abdominal tenderness, peritonitis, hemodynamic instability, major acute abdominal pain despite gastric decompression, or CT scan findings of small bowel ischemia. Nonoperative management was proposed to patients who did not need emergency surgery. A gastric decompression with a nasogastric tube was immediately performed in the emergency room for four hours, then the nasogastric tube was clamped and 100 ml of nondiluted oral Gastrografin® was administered. The nasogastric tube remained clamped for eight hours and an abdominal plain radiograph was taken after that period. Emergency surgery was then performed in patients who had persistent abdominal pain, onset of abdominal tenderness or vomiting during the clamping test, or if the abdominal plain radiograph did not show contrast product in the colon or the rectum. In other cases, the nasogastric tube was removed and a progressive refeeding was introduced, starting with liquid diet. RESULTS Seventy-eight percent of patients with SBO were managed nonoperatively, including 183 (36.0%) who finally required surgery. Delayed surgery showed a complete small bowel obstruction in all patients who failed the conservative treatment, and a small bowel resection was necessary in 19 patients (10.0%): among them, only 5 had intestinal ischemia. CONCLUSIONS Our protocol is safe, and it is a valuable strategy in order to accelerate the decision-making process for management of adhesive SBO, with a percentage of risk of late small bowel resection for ischemia esteemed at 0.9%.
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Affiliation(s)
- E Maienza
- Department of General and Endocrine Surgery, Hospital Pitié Salpêtrière, APHP, Sorbonne University Paris, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - G Godiris-Petit
- Department of General and Endocrine Surgery, Hospital Pitié Salpêtrière, APHP, Sorbonne University Paris, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - S Noullet
- Department of General and Endocrine Surgery, Hospital Pitié Salpêtrière, APHP, Sorbonne University Paris, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - F Menegaux
- Department of General and Endocrine Surgery, Hospital Pitié Salpêtrière, APHP, Sorbonne University Paris, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - N Chereau
- Department of General and Endocrine Surgery, Hospital Pitié Salpêtrière, APHP, Sorbonne University Paris, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
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4
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Podda M, Khan M, Di Saverio S. Adhesive Small Bowel Obstruction and the six w's: Who, How, Why, When, What, and Where to diagnose and operate? Scand J Surg 2021; 110:159-169. [PMID: 33511902 DOI: 10.1177/1457496920982763] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- M Podda
- Department of Emergency Surgery, Policlinico Universitario "Duilio Casula," Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - M Khan
- Department of General and Trauma Surgery, Brighton and Sussex University Hospital NHS Trust, Brighton, UK
| | - S Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Varese, Italy
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5
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Kim J, Lee Y, Yoon JH, Lee HJ, Lim YJ, Yi J, Jung WB. Non-strangulated adhesive small bowel obstruction: CT findings predicting outcome of conservative treatment. Eur Radiol 2020; 31:1597-1607. [PMID: 33128599 DOI: 10.1007/s00330-020-07406-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/24/2020] [Accepted: 10/09/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To clarify CT findings that predict outcome of conservative treatment in patients with non-strangulated adhesive small bowel obstruction (SBO). METHODS Unenhanced and contrast-enhanced abdominopelvic CT studies in 189 patients with adhesive SBO who had initial conservative treatment were reviewed. The CT findings included transition zone, beak signs, maximum bowel diameter, bowel diameter ratio, decreased bowel wall enhancement, increased unenhanced bowel wall attenuation, anterior parietal adhesion, bowel wall thickening, closed-loop obstruction, small bowel feces sign, whirl sign, mesenteric haziness, mesenteric, peritoneal fluid, and submucosal edema. These findings were statistically compared according to the success or failure of treatment. RESULTS Conservative treatment succeeded in 144 patients (76.2%) and failed in 45 patients (23.8%). At multivariate analysis, the lack of small bowel feces sign, focal, diffuse mesenteric haziness, and moderate amount of mesenteric fluid were independent findings predicting failure of conservative treatment, with odds ratios of 5.23, 5.5, 13.55, and 4.89, respectively. The presence of all significant findings showed a high specificity of 97.2% with positive likelihood ratio of 8.8. If CT scans showed none of the three significant findings, the negative predictive value was 97.6% and negative likelihood ratio was 0.08. CONCLUSIONS The lack of small bowel feces sign, focal, diffuse mesenteric haziness, and moderate amount of mesenteric fluid are independent CT findings predicting the failure of conservative treatment in patients with non-strangulated adhesive SBO. The combination of all CT findings suggests the need for surgery; absence of two or all CT findings should suggest an attempt for conservative treatment. KEY POINTS • To minimize delayed operation, it is important to identify non-strangulated adhesive small bowel obstruction patients in whom initial conservative treatment is likely to fail. • The lack of small bowel feces sign, the presence of mesenteric haziness, and a moderate amount of mesenteric fluid are independent factors predicting the failure of conservative treatment in patients with non-strangulated adhesive small bowel obstruction. • The combination of all three CT findings suggests the need for surgery; absence of two or all three CT findings should suggest an attempt for conservative treatment.
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Affiliation(s)
- Jieun Kim
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea.,Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yedaun Lee
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea.
| | - Jung-Hee Yoon
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Ho-Joon Lee
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Yun-Jung Lim
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Jisook Yi
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Won Beom Jung
- Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
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6
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Schowalter S, Altawil Z, Schechter-Perkins EM, Pare JR. False Elevation of Volume Determined by Bladder Scanner Secondary to Bowel Obstruction. Clin Pract Cases Emerg Med 2020; 4:158-160. [PMID: 32426660 PMCID: PMC7220021 DOI: 10.5811/cpcem.2019.12.45103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 11/29/2019] [Accepted: 12/19/2019] [Indexed: 01/11/2023] Open
Abstract
Bladder scanners allow for quick determination of bladder volumes (BV) with minimal training. BV measured by a machine is generally accurate; however, circumstances exist in which falsely elevated BVs are reported. This case details a patient with a significant small bowel obstruction (SBO) due to superior mesenteric artery syndrome causing a falsely elevated BV. We believe this is the first case report of a SBO causing an elevated BV by bladder scanner. Emergency physicians should be aware of the pitfalls of using bladder scanners, and use their point-of-care ultrasound skills when possible to expand their differential.
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Affiliation(s)
- Sean Schowalter
- Beth Israel Deaconess Medical Center, Department of Internal Medicine, Boston, Massachusetts
| | - Zaid Altawil
- Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | | | - Joseph R Pare
- Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts
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7
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Behman R, Nathens AB, Haas B, Look Hong N, Pechlivanoglou P, Karanicolas P. Population-based study of the impact of small bowel obstruction due to adhesions on short- and medium-term mortality. Br J Surg 2019; 106:1847-1854. [PMID: 31397896 DOI: 10.1002/bjs.11284] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/20/2019] [Accepted: 05/23/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Small bowel obstruction due to adhesions (aSBO) is a common indication for admission to a surgical unit. Despite the prevalence of this condition, the short- and medium-term survival of this patient population has not been well described. The purpose of this study was to measure the short- and medium-term survival of patients admitted to hospital with aSBO. METHODS Linked administrative data were used to identify patients admitted to hospital in Ontario, Canada, for aSBO between 2005 and 2011. Patients were divided into two groups: those aged less than 65 years (younger group) and those aged 65 years and older (older group). Thirty-day, 90-day and 1-year mortality rates were estimated. One-year mortality was compared with that in the general population, adjusting for age and sex. The timing of deaths in relation to admission was assessed, as well as the proportion of patients discharged before experiencing short-term mortality. RESULTS There were 22 197 patients admitted to hospital for aSBO for the first time in the study interval. Mean age was 64·5 years and 52·2 per cent of the patients were women. Overall, the 30-day, 90-day and 1-year mortality rates for the cohort were 5·7 (95 per cent c.i. 5·4 to 6·0), 8·7 (8·3 to 9·0) and 13·9 (13·4 to 14·3) per cent respectively. For both groups, the 1-year risk of death was significantly greater than that of the age-matched general population. The majority of deaths (62·5 per cent) occurred within 90 days of admission, with 36·4 per cent occurring after discharge from the aSBO admission. CONCLUSION Patients admitted with aSBO have a high short-term mortality rate. Increased monitoring of patients in the early period after admission is advisable.
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Affiliation(s)
- R Behman
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - A B Nathens
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - B Haas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - N Look Hong
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - P Pechlivanoglou
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
| | - P Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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8
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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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9
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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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10
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Köstenbauer JK. Managing Adhesive Small Bowel Obstruction with Water-Soluble Contrast Should Be Protocolized: A Retrospective Analysis. Surg J (N Y) 2018; 4:e123-e128. [PMID: 30038961 PMCID: PMC6054586 DOI: 10.1055/s-0038-1666781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/16/2018] [Indexed: 12/13/2022] Open
Abstract
Aim
Current literature emphasizes the effectiveness of computed tomography (CT) and water-soluble contrast agent, Gastrografin, in the investigation of adhesive small bowel obstruction (ASBO). As there is no management protocol for ASBO at our institution, the aim of this study was to determine the effect of imaging methods—CT, Gastrografin challenge (GC), or plain-film X-ray—on patient outcomes in a clinical setting.
Methods
All 163 emergency presentations of ASBO during the study period between December 2010 and September 2012 were collected retrospectively. Cases were divided into three groups: CT with oral contrast, GC, or plain-film X-ray only. The primary outcome was time to theater.
Results
Patients investigated with X-ray only were significantly less likely to require surgery (6% in plain-film X-ray vs. 35% and 20% in CT and GC, respectively;
p
= 0.003). In cases requiring surgery, GC was associated with a 24-hour longer time to imaging than CT (
p
< 0.001). The time to theater was 71:25 hours for GC versus 46:39 for CT (
p
= 0.039). There was no significant difference in bowel resection or complication rates.
Conclusion
Patients undergoing water-soluble contrast studies were subjected to unnecessary delays in their clinical course. These delays are costly and avoidable. The development and implementation of an evidence-based protocol for the management of small bowel obstruction is strongly recommended. The lack of a protocol likely caused significant delays in Gastrografin administration, reducing its known benefits for clinical decision-making and length of stay.
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Affiliation(s)
- Jakob K Köstenbauer
- Department of Surgery, University of New South Wales, Wagga Wagga Rural Referral Hospital, Wagga Wagga, New South Wales, Australia
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11
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Köstenbauer J, Truskett PG. Current management of adhesive small bowel obstruction. ANZ J Surg 2018; 88:1117-1122. [PMID: 29756678 DOI: 10.1111/ans.14556] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 01/25/2018] [Accepted: 02/28/2018] [Indexed: 12/20/2022]
Abstract
Small bowel obstruction is a common and significant surgical presentation. Approximately 30% of presentations will require surgery during admission. The great challenge of adhesive small bowel obstruction (ASBO) management is the early detection of silent intestinal ischaemia in patients initially deemed suitable for conservative therapy. Recent literature emphasizes the effectiveness of computed tomography enterography and water-soluble contrast studies in the management of ASBO. Low-volume undiluted water-soluble contrast has been shown to have both triage and therapeutic value in the management of ASBO. Their use has been demonstrated to reduce the need for surgery to below 20%. There has also been growing interest in clinicoradiological algorithms which aim to predict ischaemia early in the course of presentation. The aim of this review is to summarize the latest evidence and clarify previous uncertainties, specifically regarding the duration of conservative treatment, timing of contrast studies and the reliability of predictive algorithms. Based on this latest evidence, we have formulated a management protocol which aims to integrate these latest developments and formalize a strategy for best management in ASBO.
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Affiliation(s)
- Jakob Köstenbauer
- Rural Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Surgery, Wagga Wagga Rural Referral Hospital, Wagga Wagga, New South Wales, Australia
| | - Philip G Truskett
- Rural Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Department of General Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
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12
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Affiliation(s)
- Christopher T Aquina
- Department of Surgery, University of Rochester Medical Center, Box SURG, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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13
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Utility of RDW in Prediction of Strangulation in Emergency Setting Hernias. Int Surg 2015. [DOI: 10.9738/intsurg-d-15-00030.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Most of the small bowel obstruction cases are due to adhesions and hernias. Identifying strangulated cases may save patients from consequences of unnecessary operations and save patients who need urgent intervention by early detection. Serum markers of intestinal ischemia may help to identify and detect strangulation. The aim of this study was to identify if certain blood values such as RDW can accurately predict presence of strangulation preoperatively. We reviewed files of 127 patients who were operated because of incarcerated abdominal hernias for serum biomarkers and evaluated them with the operative findings. Our results show that elevation in red cell distribution width and white blood cell count may reflect strangulation. These findings may be useful in identifying the strangulated cases that need urgent surgical intervention.
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14
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Springer JE, Bailey JG, Davis PJB, Johnson PM. Management and outcomes of small bowel obstruction in older adult patients: a prospective cohort study. Can J Surg 2015; 57:379-84. [PMID: 25421079 DOI: 10.1503/cjs.029513] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The purpose of this research was to examine the morbidity, mortality and rate of recurrent bowel obstruction associated with the treatment of small bowel obstruction (SBO) in older adults. METHODS We prospectively enrolled all patients 70 years or older with an SBO who were admitted to a tertiary care teaching centre between Jul. 1, 2011, and Sept. 30, 2012. Data regarding presentation, investigations, treatment and outcomes were collected. RESULTS Of the 104 patients admitted with an SBO, 49% were managed nonoperatively and 51% underwent surgery. Patients who underwent surgery experienced more complications (64% v. 27%, p = 0.002) and stayed in hospital longer (10 v. 3 d, p < 0.001) than patients managed nonoperatively. Nonoperative management was associated with a high rate of recurrent SBO: 31% after a median follow-up of 17 months. Of the patients managed operatively, 60% underwent immediate surgery and 40% underwent surgery after attempted nonoperative management. Patients in whom nonoperative management failed underwent surgery after a median of 2 days, and 89% underwent surgery within 5 days. The rate of bowel resection was high (29%) among those who underwent delayed surgery. Surgery after failed nonoperative management was associated with a mortality of 14% versus 3% for those who underwent immediate surgery; however, this difference was not significant. CONCLUSION These data suggest that some elderly patients with SBO may be waiting too long for surgery.
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Affiliation(s)
| | | | - Philip J B Davis
- The Division of General Surgery, Dalhousie University, Halifax, NS
| | - Paul M Johnson
- The Division of General Surgery and the Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS
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15
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Early Operation Is Associated With a Survival Benefit for Patients With Adhesive Bowel Obstruction. Ann Surg 2013; 258:459-65. [DOI: 10.1097/sla.0b013e3182a1b100] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Goussous N, Eiken PW, Bannon MP, Zielinski MD. Enhancement of a small bowel obstruction model using the gastrografin® challenge test. J Gastrointest Surg 2013; 17:110-6; discussion p.116-7. [PMID: 22923211 DOI: 10.1007/s11605-012-2011-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 08/14/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Based on a previous published data on small bowel obstruction (SBO), a management model for predicting the need for exploration has been adopted in our institution. In our model, patients presenting with three criteria-the history of obstipation, the presence of mesenteric edema, and the lack of small bowel fecalization on computed tomography (CT)-undergo exploration. Patients with two or less features were managed nonoperatively. An alternative tool for predicting need for operative intervention is Gastrografin (GG) challenge test. HYPOTHESIS We hypothesized that the GG challenge test, when used in combination with our prior model, will decrease the rate of explorations in patients not meeting the criteria for immediate operation. METHODS An approval from IRB was obtained to review patients admitted with a diagnosis of SBO from November 2010 to September 2011. All patients presenting with signs of ischemia, patients with all three model criteria defined previously, and those who had an abdominal operation within 6 weeks of diagnosis were excluded. All patients had an abdominal/pelvic CT and GG challenge at the time of diagnosis. Patients were compared to historic controls managed without the GG challenge (from July to December 2009). Successful GG challenge was defined as the presence of contrast in the colon after a follow-up film or a bowel movement. Data were presented as medians or percentages; significance was considered at p < 0.05. RESULTS One hundred and twenty-five patients with a diagnosis of small bowel obstruction were identified wherein 47 % were males. Fifty-three received a GG challenge (study), and 72 did not have a GG challenge (historic). There was no difference in age (70 vs 65 years), history of prior SBO (51 vs 49 %), history of diabetes mellitus (21 vs 18 %), history of malignancy (32 vs 39 %), or cardiac disease (30 vs 39 %). Both groups had similar number of previous abdominal operations (two vs two). The presence of mesenteric edema (68 vs 75 %), the lack of small bowel fecalization (47 vs 46 %), and a history of obstipation (25 vs 24 %) were similar in both groups. Patients in the study group had a lesser rate of abdominal exploration (25 vs 42 %, p = 0.05) and fewer complications (13 vs 31 %, p = 0.02) compared to the historic control group. There was equivalent incidence of ischemic bowel (4 vs 7 %), duration of hospital stay (4 vs 7 days), duration from admission to operation (2 vs 3 days), and mortality (8 vs 6 %); 44 patients had a successful GG challenge with nine failures. There was a greater rate of exploration in patients with a failed challenge compared to those with a successful challenge (89 vs 11 %, p < 0.01). CONCLUSION The use of the GG challenge enhanced the SBO prediction model by decreasing the need for exploration in patients not meeting the criteria for immediate operation. Patients who failed the GG challenge test were much more likely to undergo an exploration.
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Affiliation(s)
- Naeem Goussous
- Department of General Surgery, Mayo Clinic, Rochester, MN 55902, USA
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17
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Lien I, Wong SW, Malouf P, Truskett PG. Effect of handover on the outcomes of small bowel obstruction in an acute care surgery model. ANZ J Surg 2012; 84:442-7. [PMID: 22985492 DOI: 10.1111/j.1445-2197.2012.06248.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND An acute care surgery (ACS) model was introduced to manage emergency surgical presentations efficiently. The aim of this study was to evaluate the impact of patient handover in an ACS model on the outcomes of adhesive small bowel obstruction (SBO). METHODS A retrospective study was performed on patients who were admitted with adhesive SBO at Prince of Wales Hospital. The cohort consisted of all patients treated by the ACS team from its introduction in September 2005 to February 2011. Patients in the ACS cohort were divided into two groups: those whose care was handed over to another surgeon and those whose care was not. These groups of patients were compared with a random sample of 50 patients in the pre-ACS period. RESULTS In the ACS period, there was no significant difference in complication rates or length of hospital stay in those who were not handed over and those who were. A significantly higher proportion of operations took place during the day for the group who had been handed over (72.7% versus 36.7%; P = 0.005). There were no significant differences in complication rates or length of hospital stay in the pre-ACS and ACS period. CONCLUSION Management under an ACS team does not increase adverse outcomes for adhesive SBO. Patients can be safely handed over within an ACS framework. Other members of the ACS team may help facilitate continuity of care.
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Affiliation(s)
- Ivy Lien
- Department of Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
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18
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Development of a simple model for predicting need for surgery in patients who initially undergo conservative management for adhesive small bowel obstruction. Am J Surg 2010; 200:215-23. [PMID: 20591400 DOI: 10.1016/j.amjsurg.2009.07.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 06/05/2009] [Accepted: 07/09/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Among patients with adhesive small bowel obstruction (ASBO) initially managed with a conservative strategy, predicting risk of operation is difficult. METHODS We investigated ASBO patients at 2 different periods to derive and validate a clinical prediction model for risk of operation. RESULTS One hundred fifty-four patients were enrolled into the derivation cohort and 96 into the validation cohort. Based on the derived scoring, including age > or =65 years, presence of ascites, and gastrointestinal drainage volume >500 mL on day 3, each patient was classified into 1 of 4 risk classes from low risk to high risk. When applied to the validation cohort, the positive predictive value (PPV) for operation in the high-risk class was 72%, while the negative predictive value (NPV) in the low-risk class was 100% with high sensitivity (100%) and specificity (96%). CONCLUSIONS The prediction model performs well for risk stratification of need for surgical intervention following conservative strategy among ASBO patients.
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Kobayashi S, Matsuura K, Matsushima K, Okubo K, Henzan E, Maeshiro M. Effectiveness of diagnostic paracentesis and ascites analysis for suspected strangulation obstruction. J Gastrointest Surg 2007; 11:240-6. [PMID: 17458593 DOI: 10.1007/s11605-007-0092-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Strangulation obstruction is a surgical emergency, but its accurate diagnosis and timely surgical treatment are still matters of debate. We conducted a prospective observational study. We performed diagnostic paracentesis preoperatively for patients with suspected strangulation obstruction or, if that was impossible, we obtained ascites at the time of laparotomy. We examined each specimen to see whether ascites color and laboratory parameters could be reliable indicators of strangulation obstruction. During 18 months, 32 patients had suspected strangulation obstruction. At laparotomy, we confirmed strangulation obstruction in 21 patients, simple obstruction in two patients, and pseudo-obstruction in one patient. We treated eight patients conservatively, including one patient with a complication. We identified ascites red blood cell count, hematocrit, and lactic acid as indicators for strangulation obstruction by univariate analysis. An ascites red blood cell count was statistically high in cases with strangulation obstruction by multivariate analysis. Ascites red blood cell count above 20,000/mm(3) had a positive predictive value for strangulation obstruction of 100%, and above 40,000/mm(3), bowel resection was highly necessary. Diagnostic paracentesis and ascites analysis are useful methods for diagnosis of strangulation obstruction. Diagnostic paracentesis and ascites analysis should be combined with careful clinical exams for diagnosis of strangulation obstruction.
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Affiliation(s)
- Shin Kobayashi
- Department of Surgery, Okinawa Chubu Hospital, Okinawa, Japan.
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20
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Bickell NA, Federman AD, Aufses AH. Influence of Time on Risk of Bowel Resection in Complete Small Bowel Obstruction. J Am Coll Surg 2005; 201:847-54. [PMID: 16310687 DOI: 10.1016/j.jamcollsurg.2005.07.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2005] [Revised: 07/07/2005] [Accepted: 07/12/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Little is known about the effect of passing time on risk of resection among patients with complete small bowel obstruction. We sought to provide a benchmark of the relationship of time from symptom onset to surgical treatment on the need for resection in patients with complete small bowel obstruction. STUDY DESIGN We performed an observational study of patients with surgically treated complete small bowel obstruction at an inner-city urban tertiary referral center and a municipal hospital. Patients were sampled randomly retrospectively (n=60), and prospectively (n=81), for a final sample of 141. Detailed clinical and time data were abstracted from medical records including out-of-hospital examinations. Risk of resection was calculated using actuarial life table methods. Linear regression was used to determine factors affecting time to treatment. RESULTS All patients were treated surgically for obstruction; 45% underwent resection. Resected patients had longer (11 days versus 8 days; p=0.01) and more complicated (31% versus 14% in ICU; p=0.01) hospital stays. The risk of resection was 4% among patients with 24 hours of unresponsive symptoms; it increased to 10% to 14% through 96 hours, then dropped slightly but did not disappear. Patients treated first with a tube had longer times between first examination and operation, system-time (40.6 hours versus 10.2 hours; p=0.0007), but this was not associated with an increased resection risk. System-times were shorter among patients seen first in the emergency department (median: 25.7 hours versus 59.7 hours; p=0.0001). CONCLUSIONS Physicians should be cautious in postponing surgery beyond 24 hours in patients with unresponsive symptoms from complete obstruction. The risk of resection rises dramatically, remains elevated through 96 hours of unresolved symptoms, then declines but does not disappear.
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Affiliation(s)
- Nina A Bickell
- Department of Health Policy, Mount Sinai School of Medicine, New York, NY 10029, USA
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21
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Sauerland S, Agresta F, Bergamaschi R, Borzellino G, Budzynski A, Champault G, Fingerhut A, Isla A, Johansson M, Lundorff P, Navez B, Saad S, Neugebauer EAM. Laparoscopy for abdominal emergencies. Surg Endosc 2005; 20:14-29. [PMID: 16247571 DOI: 10.1007/s00464-005-0564-0] [Citation(s) in RCA: 227] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Accepted: 07/12/2005] [Indexed: 01/10/2023]
Abstract
BACKGROUND Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. METHODS A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. RECOMMENDATIONS Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. CONCLUSIONS Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.
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Affiliation(s)
- S Sauerland
- Institute for Research in Operative Medicine, University of Witten/Herdecke, Ostmerheimer Strasse 200, D 51109, Cologne, Germany
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22
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Mallo RD, Salem L, Lalani T, Flum DR. Computed tomography diagnosis of ischemia and complete obstruction in small bowel obstruction: a systematic review. J Gastrointest Surg 2005; 9:690-4. [PMID: 15862265 DOI: 10.1016/j.gassur.2004.10.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2004] [Revised: 10/12/2004] [Accepted: 10/18/2004] [Indexed: 01/31/2023]
Abstract
This review was designed to describe the diagnostic performance of computed tomography (CT) in assessing bowel ischemia and complete obstruction in small bowel obstruction (SBO). A MEDLINE search (1966-2004) identified 15 studies dealing with the CT diagnosis of ischemia and complete obstruction in SBO. Ischemia was defined by operative findings, and complete obstruction was defined by enteroclysis or operative findings. Aggregated sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated. Eleven of 15 studies reported on the CT diagnosis of ischemia in SBO based on 743 patients. The aggregated performance characteristics of CT for ischemia in SBO were sensitivity of 83% (range, 63-100%), specificity of 92% (range, 61-100%), PPV of 79% (range, 69-100%), and NPV of 93% (range, 33.3-100%). Seven of 15 studies evaluated the CT classification of complete obstruction based on 408 patients. The aggregated performance characteristics of CT for complete obstruction were sensitivity of 92% (range, 81-100%), specificity of 93% (range, 68-100%), PPV of 91% (range, 84-100%), and NPV of 93% (range, 76-100%). This review demonstrates the high sensitivity of CT for ischemia in the setting of SBO and suggests that a CT scan finding of partial SBO is likely to reflect a clinical condition that will resolve without surgical intervention.
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Affiliation(s)
- Rebecca D Mallo
- Department of Surgery, University of Washington, Seattle, Washington 98195-6410, USA
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Micha JP, Goldstein BH, Rettenmaier MA, Brown JV. Cecal pelvic transposition following total pelvic exenteration. Gynecol Oncol 2004; 94:589-92. [PMID: 15297211 DOI: 10.1016/j.ygyno.2004.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2004] [Indexed: 11/17/2022]
Abstract
BACKGROUND Multiple techniques have been utilized in an attempt to prevent small bowel obstructions following total pelvic exenteration. Pelvic transposition of the cecum may be an effective way to reduce the incidence of this serious complication. CASES We present three women who underwent total pelvic exenteration and cecal pelvic transposition to exclude the small bowel from the "empty pelvis". All three patients did well without any postoperative small bowel complications. CONCLUSION Cecal pelvic transposition precludes the small bowel from entering the pelvis. This procedure can be performed relatively easily by a gynecologic oncologist experienced with bowel surgery. A larger patient series is needed to assess the efficacy of this previously unpublished procedure.
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Affiliation(s)
- John P Micha
- Gynecologic Oncology Associates, Hoag Hospital Cancer Center, 351 Hospital Road, Newport Beach, CA 92663, USA.
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24
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Kössi J, Salminen P, Laato M. The epidemiology and treatment patterns of postoperative adhesion induced intestinal obstruction in Varsinais-Suomi Hospital District. Scand J Surg 2004; 93:68-72. [PMID: 15116825 DOI: 10.1177/145749690409300115] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS The epidemiology and treatment patterns of postoperative adhesion induced intestinal obstruction have been poorly investigated in Finland. This study evaluated the epidemiology and treatment patterns of postoperative adhesion induced intestinal obstruction in a well defined geographical area (Hospital District). MATERIAL AND METHODS All inpatient episodes between 1.1.1999 and 31.12.1999 due to postoperative adhesion induced intestinal obstruction in Varsinais-Suomi Hospital District were evaluated retrospectively using individual patient records. RESULTS 123 hospitalizations due to postoperative adhesion-related intestinal obstruction were observed during the study period. The total number of preceding operations was 176 considering altogether 101 patients. The most prevalent single initial operations causing adhesion induced intestinal obstruction were colorectal, upper abdominal, and female reproductive system procedures. Of all treatment episodes 32% were operative and mortality was 2%. The median days of hospital stay (range) of all inpatient episodes, operative episodes, and conservative episodes were 6 (1-58), 11 (2-34) and 4 (1-58), respectively. Patient dependent factors associated with increased likelihood to operative treatment of obstruction were: female gender (40% in females vs 23% in males, P = 0.042) and previous gynaecological surgery (70% of the patients, P = 0.032). Intraoperative findings were obstruction in 70%, strangulation in 20%, necrosis in 8%, and perforation in 2% of operations. Bowel resection was needed in 38% of operations. Preceding gynaecological surgery increased the likelihood of bowel strangulation as an intraoperative finding. CONCLUSION The epidemiology, treatment patterns and results of postoperative adhesion induced intestinal obstruction are of the average international level in the Varsinais-Suomi Hospital District. The treatment patterns among the different hospitals in the Hospital District are similar. Female gender is associated with increased risk for operative treatment of adhesive obstruction. Previous gynaecological surgery increases the likelihood of operative treatment and complicated obstruction.
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Affiliation(s)
- J Kössi
- Department of Surgery, Päijät-Häme Central Hospital, Lahti, Finland.
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