Nonoperative management of patients with a diagnosis of high-grade small bowel obstruction by computed tomography

OBJECTIVE

To determine the natural history and treatment of high-grade small bowel obstruction (HGSBO). Small bowel obstruction is a frequent complication of abdominal surgery. Complete and strangulating obstructions are managed operatively while partial obstructions receive a trial of nonoperative therapy. The management and outcome of patients with HGSBO diagnosed by computed tomography (CT) has not been examined.

DESIGN

Retrospective medical record review. Outcomes for nonoperative vs operative management were analyzed using Fisher exact and log-rank tests.

SETTING

Tertiary care referral center.

PATIENTS

One thousand five hundred sixty-eight consecutive patients admitted from the emergency department with a diagnosis of small bowel obstruction between 2000 and 2005 by CT criteria.

MAIN OUTCOME MEASURES

Recurrence of symptoms and complications.

RESULTS

One hundred forty-five patients (9%) with HGSBO were identified, with 88% follow-up (median, 332 days; range, 4-2067 days). Sixty-six (46%) were successfully managed nonoperatively while 79 (54%) required an operation. Length of stay and complications were significantly increased in the operative group (4.7 days vs 10.8 days and 3% vs 23%; P < .001). Nonoperative management was associated with a higher recurrence rate (24% vs 9%; P < .005) and shorter time to recurrence (39 days vs 105 days; P < .005) compared with operative intervention. Computed tomography signs of ischemia, admission laboratory results, and presence of cancer or inflammatory bowel disease were not predictive of an operation.

CONCLUSIONS

Patients with HGSBO by CT can be managed safely with nonoperative therapy; however, they have a significantly higher rate of recurrence requiring readmission or operation within 5 years.

Influence of imaging on the negative appendectomy rate in pregnancy

Appendectomy is the most common non-gynecologic surgery performed during pregnancy. Little data exist on the accuracy of imaging studies in the diagnosis of appendicitis in pregnancy. The objective of this study was to evaluate the probability of ultrasound and computed tomography (CT) scan in diagnosing appendicitis in pregnancy, as reflected in the negative appendectomy rate. We retrospectively reviewed the charts of 86 pregnant women who underwent an appendectomy between January 1, 1997 and January 1, 2006. Patients were divided into three groups: clinical evaluation, ultrasound, and ultrasound followed by a CT scan. The clinical evaluation group had 13 patients, with a negative appendectomy rate of 54% (7/13). Fifty-five patients underwent an ultrasound alone, with a negative appendectomy rate 36% (20/55). In the ultrasound/CT group (n=13), the negative appendectomy rate was 8% (1/13). There was a significant reduction in the negative appendectomy rate in the ultrasound/CT scan group compared to clinical evaluation group (54 vs 8%, p<0.05). This reduction was not achieved in the ultrasound group when compared to the clinical evaluation group or the ultrasound/CT group (p=0.05). A significant reduction was achieved when the ultrasound/CT group was compared to the patients in the ultrasound only group who had a normal or inconclusive ultrasound (p<0.05). Our data documents a very high negative appendectomy rate in the pregnant patient. We recommend an ultrasound followed by a CT scan in patients with a normal or inconclusive ultrasound.

Meckel's hemoperitoneum: a rare case of Meckel's diverticulitis causing intraperitoneal hemorrhage

Described here is a rare case of intraperitoneal hemorrhage caused by diverticulitis of a non-perforated, non-ectopic tissue containing Meckel's diverticulum. Literature review and pathophysiology are discussed.

Resistance to change in surgical residency: an ethnographic study of work hours reform

BACKGROUND

Although the practical challenges to work hour restrictions have been the focus of much discussion, cultural resistance to such change has received less attention. Surgical residency has its own unique social structure, and we hypothesized that challenges to this would provide impediments to successful implementation of duty hours reform.

STUDY DESIGN

We used ethnographic research methods to study the efforts at work hour restriction over a 15-month period before the introduction of the Accreditation Council for Graduate Medical Education regulations. These methods, validated for studying institutional change, build on intense periods of observation. Records of observations are then analyzed and coded to uncover cultural and political challenges. The frequency of successful hand-offs in sign-out situations between day and night float residents was measured as an objective index of success.

RESULTS

Practical issues were addressed initially by scheduling adjustments including creating a night float system. The hand-offs that this system required, however, were successful only 14% of the time. Subsequent steps to address the challenge to resident identity by top-down support of a new definition of professionalism increased the number of successful hand-offs to 39%. Finally, a reduction in a noted hierarchy violation led to successful hand-offs 79% of the time.

CONCLUSIONS

These results demonstrate that practical solutions alone may not be a sufficient basis for change in surgical residency. While we face other challenges to the traditional surgical culture, attention to social and political issues may enhance the success of our efforts.

Blunt Trauma to the Thyroid: A Case Report

Thyroid injury is a rare phenomenon in cases of blunt neck trauma. Symptoms are often subtle or not present on initial exam and can be rapidly life-threatening when airway compromise ensues. We describe the case of a 50-year-old woman who developed neck pain and swelling, dysphagia, and hoarseness after a rear-end collision in which she was the restrained driver, hitting her anterior neck against the steering wheel. Neck CT revealed fragmentation and hematoma within the right thyroid lobe. Arteriogram showed no vascular injury to the neck. The patient was observed in the ICU and was discharged home 3 days later without operative intervention. We believe that in the acute setting, a stable traumatic thyroid hematoma without airway encroachment may be safely observed. Increasing size or compromise of airway integrity should be indications for early intubation and neck exploration.

Blunt trauma to the thyroid: a case report

Thyroid injury is a rare phenomenon in cases of blunt neck trauma. Symptoms are often subtle or not present on initial exam and can be rapidly life-threatening when airway compromise ensues. We describe the case of a 50-year-old woman who developed neck pain and swelling, dysphagia, and hoarseness after a rear-end collision in which she was the restrained driver, hitting her anterior neck against the steering wheel. Neck CT revealed fragmentation and hematoma within the right thyroid lobe. Arteriogram showed no vascular injury to the neck. The patient was observed in the ICU and was discharged home 3 days later without operative intervention. We believe that in the acute setting, a stable traumatic thyroid hematoma without airway encroachment may be safely observed. Increasing size or compromise of airway integrity should be indications for early intubation and neck exploration.

Maternal congenital diaphragmatic hernia complicating pregnancy

BACKGROUND

Symptomatic maternal diaphragmatic hernia in a pregnant woman is a surgical emergency associated with high morbidity and mortality both for her and her fetus. Such patients are most commonly managed with immediate cesarean delivery combined with hernia repair.

CASE

A woman presented at 29 weeks' gestation with symptoms of bowel obstruction due to herniation of viscera through a previously undiagnosed congenital diaphragmatic hernia of Bochdalek, and she was stabilized. Antenatal corticosteroids were administered to facilitate fetal maturity. The hernia was repaired 10 days after her presentation because of evidence of incarceration. Labor was induced at 39 weeks' gestation, and a healthy infant was delivered vaginally.

CONCLUSION

Expectant management and vaginal delivery after antepartum repair of congenital diaphragmatic hernia in the mother is a reasonable alternative to immediate cesarean delivery.

Hepatic Duct Confluence Injury in Blunt Abdominal Trauma: Case Report and Synopsis on Management

Injuries of the extra hepatic biliary tree following blunt trauma to the abdomen are rare. We present here a case of injury to the confluence of the hepatic ducts and a brief synopsis on diagnosis and management of blunt injury to the extrahepatic biliary system.

Dynamic aortomyoplasty: clinical experience and thoracoscopic surgery feasibility study

BACKGROUND

Surgical procedures using the latissimus dorsi (LD) muscle to assist chronic heart failure inflict major trauma on severely sick patients. A less invasive approach may prove beneficial. The aim of this article is to review our clinical and experimental approaches of dynamic aortomyoplasty (AMP) and emphasize the necessity to reorient surgical technique towards new directions and a less invasive thoracoscopic approach.

MATERIALS AND METHODS

A clinical pilot study on dynamic descending AMP started in June 1995 and included four patients. Two of them could benefit from LD counterpulsation, surviving 6 months and 18 months. Following this clinical experience, we investigated, on an animal model, minimally invasive thoracoscopic surgery for this procedure. Twelve goats underwent endoscopic LD harvest and video-assisted aortic wrap, and were studied after surgical recovery from an anatomical and functional standpoint.

RESULTS

Clinical AMP using open techniques provided extraaortic counterpulsation in NYHA Class IV patients contraindicated for other surgical therapies. However, surgical technique and strategy needed improvements for optimal cardiac assistance and better patient outcome. Minimally invasive thoracoscopic surgery was feasible and reproducible in goats, achieving improved anatomy and physiology as compared to the open technique in humans. When appropriate the wrapping technique and stimulation protocol were used, an optimal counterpulsation was demonstrated. We concluded that thoracoscopic AMP may provide a minimally invasive approach to cardiac assistance and thus, a new surgical option for patients presenting with chronic heart failure.

Innovative techniques in skeletal muscle cardiac assistance: first experimental study on minimally invasive aortomyoplasty and cardiomyoplasty

Skeletal muscle cardiac assistance as a treatment modality for heart failure is considered a high-risk procedure subject to strict patient selection. The aim here is to develop minimally invasive techniques to improve surgical outcomes and increase clinical indications. Ten goats (45-55 kg) were studied. In six, the latissimus dorsi muscle (LDM) was harvested via an open technique on one side vs a minimally invasive technique on the other using video assistance through two 3 cm incisions. Surgical maneuvers and length of procedures were noted. Animals were recovered, observed daily for local complications, and killed after 1 week for comparative anatomic and histopathologic studies. In four other goats, minimally invasive aortomyoplasty or cardiomyoplasty was performed using video assistance (2 aortomyoplasty, 2 cardiomyoplasty). In this experimental series, there were no surgical complications. The minimally invasive LDM harvest required a mean of 81 min (range 55-116 mn) with no gross evidence of muscle damage. The technique of LDM harvesting was standardized and is reproducible. Aortic and cardiac wraping were also achieved through three ports and a left minithoracotomy of 4 cm, using the right or left LDM. A scarf technique for the descending aortomyoplasty using the left LDM, and an anterior wrapping for cardiomyoplasty using the left or right LDM was technically feasible with video assistance. This study suggests future clinical applicability.

Does aggressive medical therapy for acute ulcerative colitis result in a higher incidence of staged colectomy?

BACKGROUND

Colectomy with ileal pouch-anal anastomosis is the operation of choice in patients with medically refractory ulcerative colitis. However, aggressive or prolonged medical treatment may result in the patient's needing an urgent operation in which a staged subtotal colectomy is necessary.

OBJECTIVE

Our hypothesis is that the incidence of patients requiring a staged approach has increased, along with an increase in hospital stay and total hospital costs.

DESIGN

We examined the medical records of 250 consecutive patients with ulcerative colitis who underwent ileal pouch-anal anastomosis between 1984 and 1993.

RESULTS

Simultaneous colectomy and ileal pouch-anal anastomosis were performed in 196 patients (78%), while 54 patients (21.6%) required staged subtotal (78%) or partial colectomy (22%). Indications for initial colectomy included failure of medical therapy (42 patients [77.8%]), undifferentiated colitis (five patients [9.3%]), and perforation (six patients [11.1%]). An increase in the incidence of patients requiring staged colectomy during this period was observed (P < .05). Staged procedures led to a prolonged hospital course at a significantly greater total cost.

CONCLUSION

We conclude that aggressive medical therapy of acute ulcerative colitis has increased the incidence of urgent staged colectomy with a resulting increase in morbidity, hospital stay, and cost and a less-optimal functional result.

Counterregulation of a prokinetic calcium-dependent mechanism by cAMP-dependent agents in isolated segments of terminal ileum

The ill-understood complex of the irritable bowel syndrome comprises a group of intestinal motility disorders characterized by increased intraluminal pressures and decreased transit times. Elucidation of mechanisms which modulate gut motility may lead to the development of rational therapy for this prevalent problem. The purpose of this study was firstly to evaluate the interaction of cAMP-dependent agents (vasoactive intestinal polypeptide (VIP), norepinephrine (NE), and forskolin (FK)) on carbachol (Ca2+)-initiated motility and secondly to determine if a neural component of motility modulation existed by testing if the effect of cAMP-dependent agents was reversed by tetrodotoxin-induced neural blockade. Motility was measured in isolated segments of terminal ileum harvested from rabbits using perfusion manometry and quantitated by integration, expressed as mm Hg/min. Carbachol caused a concentration-dependent increase in measured motor activity (half-effective dose = 10(-7) M). VIP, NE, and FK each caused a concentration-dependent inhibition of carbachol-stimulated phasic contractions. TTX 10(-6) M failed to block the inhibitory actions of NE. In conclusion, these results suggest that cAMP-dependent mechanisms may inhibit gut motility induced by a cholinergic (Ca2+)-mediated agonist and that this process is mediated by a nonneural mechanism.