[Timing of surgery, intestinal ischemia and other real factors of mortality in acute adhesive small bowel obstruction: a multiple-center study]

Intestinal fatty acid-binding protein (I-FABP) as biomarker of ischemic damage in experimentally induced 12-h small bowel obstruction

Laboratory tests have low diagnostic specificity for strangulated intestinal obstruction. The diagnostic potential of the intestinal fatty acid-binding protein (I-FABP) expressed in the tips of the intestinal villi continues to be explored. The number of white blood cells, blood plasma levels of L-lactate, C-reactive protein (CRP) and I-FABP were measured in rats with experimentally induced 12-h strangulated and non-strangulated intestinal obstruction. The results of the laboratory tests were compared with the changes in the morphology of the intestinal wall. The studied diagnostic markers, except for CRP, were elevated by 12-h L-lactate and I-FABP concentrations were significantly higher in the strangulated obstruction group than in other groups. L-lactate (cutoff value: 3.01 mmol/L) had 86.1% sensitivity and 66.7% specificity for strangulated obstruction (AUC 0.815, p < 0.001). I-FABP levels above 5.432 ng/ml indicated strangulated obstruction with 83.33% sensitivity and 88.9% specificity (AUC 0.906, p < 0.001). Villi destruction was observed at 2 h in the strangulated obstruction group. I-FABP levels peaked at 4 h and plateaued at 12 h. Functional changes were observed in the non-strangulated group; they were accompanied by a significant increase in I-FABP concentrations that lasted until 12 h. Compared with traditional diagnostic markers of strangulated intestinal obstruction, I-FABP demonstrated higher accuracy in the first 12 h, although its concentrations reached the plateau already at 4 h and did not increase thereafter. The functional changes in small bowel wall in non-strangulated obstruction were accompanied by continuous increase in I-FABP concentrations up to 12 h, which may have influenced the diagnostic accuracy of the marker.

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

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Analysis of Placement Priorities and Nursing Countermeasures of Transnasally Inserted Intestinal Obstruction Catheters in Patients with Acute Small Bowel Obstruction

Objective

To explore the placement priorities and analysis of nursing countermeasures of transnasally inserted intestinal obstruction catheters in patients with acute small bowel obstruction (ASBO).

Methods

One hundred and three patients with ASBO treated in our hospital from May 2016 to February 2022 were enrolled to this study. Patients who received individual nursing for transnasally inserted intestinal obstruction catheters were considered as the observation group (n = 59) and those who received traditional nursing were regarded as the control group (n = 44). The symptom relief time, daily gastrointestinal decompression, bowel sound recovery time, exhaust, defecation recovery time, and gas-liquid plane disappearance time were compared between both groups. The abdominal pain was evaluated by visual analogue scale (VAS), and the psychology of patients was evaluated by self-rating anxiety scale (SAS) and self-rating depression scale (SDS). Patients' clinical efficacy and incidence of adverse effects were counted, and quality of life was assessed using the short form 36 (SF-36) health survey questionnaire.

Results

In the observation group, the improvement time of clinical symptoms and VAS, SAS, and SDS scores after intubation were lower than those of the control group, while the total clinical treatment efficiency was higher (P < 0.05). As to the adverse effects, the observation group was lower than the control group (P < 0.05). Also, the SF-36 scores were higher than those of the control group in all dimensions (P < 0.05).

Conclusion

The individual nursing strategy implemented for the transnasally inserted intestinal obstruction catheter can effectively shorten the recovery of ASBO patients and improve their treatment outcome and prognosis quality of life.

[Preoperative diagnosis of intestinal ischemia in small bowel obstruction. Only computed tomography? A multiple-center observational study]

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.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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