Proximal small bowel obstruction in a patient with cystic fibrosis: a case report

Abdominal Surgical Procedures in Adult Patients With Cystic Fibrosis: What Are the Risks?

BACKGROUND

With advances in medical care, patients with cystic fibrosis are more commonly living into adulthood, yet there are limited data describing the need for GI surgery and its outcomes in adult cystic fibrosis patients.

OBJECTIVE

We aim to use a national administrative database to evaluate trends in abdominal GI surgery and associated postoperative outcomes among adult cystic fibrosis patients.

DESIGN

This was a national retrospective cohort study.

SETTING

A national all-payor administrative database from 2000 to 2014 was used.

PATIENTS

Patients included adults (age ≥18 years) with cystic fibrosis undergoing abdominal GI surgery.

MAIN OUTCOME MEASURES

The primary outcome was trend over time in number of surgical admissions. Secondary outcomes included morbidity and mortality by procedure type.

RESULTS

We identified 3075 admissions for abdominal surgery, of which 28% were elective. Major GI surgical procedures increased over the study period ( p < 0.01), whereas appendectomy and cholecystectomy did not demonstrate a clear trend ( p = 0.90). The most common procedure performed was cholecystectomy ( n = 1280; 42%). The most common major surgery was segmental colectomy ( n = 535; 18%). Obstruction was the most common surgical indication ( n = 780; 26%). For major surgery, in-hospital mortality was 6%, morbidity was 37%, and mean length of stay was 15.9 days (SE 1.2).

LIMITATIONS

The study is limited by a lack of granular physiological and clinical data within the administrative data source.

CONCLUSIONS

Major surgical admissions for adult patients with cystic fibrosis are increasing, with the majority being nonelective. Major surgery is associated with significant morbidity, mortality, and prolonged length of hospital stay. These findings may inform perioperative risk for adult patients with cystic fibrosis in need of GI surgery. See Video Abstract at http://links.lww.com/DCR/B850 .

PROCEDIMIENTOS QUIRRGICOS ABDOMINALES EN PACIENTES ADULTOS CON FIBROSIS QUSTICA CULES SON LOS RIESGOS

ANTECEDENTES:Con los avances en la medicina, los pacientes con fibrosis quística viven más comúnmente hasta la edad adulta, pero hay datos escasos que describan la necesidad de cirugía gastrointestinal y sus resultados en pacientes adultos con fibrosis quística.OBJETIVO:Nuestro objetivo es utilizar una base de datos administrativa nacional para evaluar las tendencias en la cirugía gastrointestinal abdominal y los resultados posoperatorios asociados entre los pacientes adultos con fibrosis quística.DISEÑO:Estudio de cohorte retrospectivo nacional.AJUSTE:Base de datos administrativa nacional de todas las instituciones pagadoras desde 2000 a 2014.PACIENTES:Todos los pacientes adultos (edad> 18) con fibrosis quística sometidos a cirugía gastrointestinal abdominal.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la tendencia a lo largo del tiempo en el número de ingresos quirúrgicos. Los resultados secundarios incluyeron morbilidad y mortalidad por tipo de procedimiento.RESULTADOS:Identificamos 3.075 ingresos por cirugía abdominal de los cuales el 28% fueron electivos. Los procedimientos quirúrgicos gastrointestinales mayores aumentaron durante el período de estudio (p <0,01) mientras que la apendicectomía y la colecistectomía no demostraron una tendencia clara (p = 0,90). El procedimiento realizado con mayor frecuencia fue la colecistectomía (n = 1.280; 42%). La cirugía mayor más común fue la colectomía segmentaria (n = 535; 18%). La obstrucción fue la indicación quirúrgica más común (n = 780; 26%). Para la cirugía mayor, la mortalidad hospitalaria fue del 6%, la morbilidad del 37% y la estadía media de 15,9 días (EE 1,2).LIMITACIONES:El estudio está limitado por la falta de datos clínicos y fisiológicos granulares dentro de la fuente de datos administrativos.CONCLUSIONES:Los ingresos quirúrgicos mayores de pacientes adultos con fibrosis quística están aumentando y la mayoría no son electivos. La cirugía mayor se asocia con una morbilidad y mortalidad significativas y una estancia hospitalaria prolongada. Estos hallazgos pueden informar el riesgo perioperatorio para pacientes adultos con fibrosis quística que necesitan cirugía gastrointestinal. Consulte Video Resumen en http://links.lww.com/DCR/B850 . (Traducción-Dr. Felipe Bellolio ).

Laparoscopic surgery in patients with cystic fibrosis: A systematic review

INTRODUCTION

Laparoscopic surgery may be advantageous for cystic fibrosis (CF) patients because it leads to fewer complications than open surgery. However, it could still lead to pulmonary and cardiovascular complications in CF patients. We aimed to systematically review the use of laparoscopic surgery in CF patients.

METHODS

A systematic review was performed in compliance with PRISMA guidelines. A literature search was performed using PubMed/MEDLINE, ScienceDirect, EMBASE, and Google Scholar, with "cystic fibrosis and laparoscopic surgery" and "cystic fibrosis and minimally invasive surgery" used as the search terms. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria were applied. The protocol was registered with the PROSPERO register.

RESULTS

Six studies met the predetermined inclusion criteria; accordingly, two studies provided high-quality evidence and four provided moderate-quality evidence. The interrater correlation was convincing (r_s  = .95, P = .02, two-tailed). Therefore, three quantitative studies and three qualitative studies were assessed and evidence-graded in accordance with the GRADE protocol.

CONCLUSION

The benefits of laparoscopic surgical interventions for patients with CF were supported with good evidential value and recognized as a safe and suitable surgical option.

Proximal intestinal obstruction syndrome (PIOS) in a patient with cystic fibrosis: A case report

Introduction

Distal Intestinal Obstruction Syndrome is a rare complication in patients with cystic fibrosis, which characterized by the accumulation of viscid fecal material, combined with sticky mucous secretions located in the distal ileum adhere to the intestinal wall, causing complete bowel obstruction.

Presentation of case

We report a case of a 45 years old patient with cystic fibrosis, who presented bowel obstruction secondary to accumulation of fecal material, combined with mucous secretions, in the mid-jejunum. A diagnostic laparoscopy was performed where a dilated jejunum was encountered with impaction of fecal content. Surgery was converted to open surgery, where a longitudinal enterotomy of 5 cm after the transition zone was created, evacuating manually the fecal material with mucous secretion. The patient evolved favorably, without complications.

Discussion

We present a case of a patient with cystic fibrosis presenting with bowel obstruction due to a proximal intestinal obstruction syndrome, which can be diagnosed with the DIOS definition, with the only distinction of a more proximal location in the gastrointestinal tract, such as the stomach, the duodenum, or the jejunum.

Conclusion

It is important for the clinician to know the existence of this syndrome at its different locations in the small bowel to treat accordingly.

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Proximal Intestinal Obstruction Syndrome is a rare complication in patients with cystic fibrosis.

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It is the accumulation of viscid feces with mucous secretions in the small bowel.

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It is important to know the existence of this syndrome to treat accordingly.