Ultrasound Visceral Slide Assessment to Evaluate for Intra-abdominal Adhesions in Patients Undergoing Abdominal Surgery - A Systematic Review and Meta-analysis

OBJECTIVE

Abdominal entry at the time of laparoscopy is a critical step with a risk of injury to underlying viscera owing to bowel adhesions. Ultrasound can be used as a preoperative tool to assess the slide of viscera underneath the abdominal wall to detect adhesion-free areas. The objective of this systematic review and meta-analysis was to determine the diagnostic accuracy of preoperative visceral slide assessment with ultrasound to detect intra-abdominal adhesions, compared with the gold standard of intraoperative findings.

DATA SOURCES

Using Cochrane, Medline PubMed, Embase, and Google Scholar electronic databases, 3737 articles were screened in April 2020 using a query that included variations of "adhesions" and "ultrasound." Reference lists of relevant articles were searched for further articles.

METHODS OF STUDY SELECTION

Prospective and cross-sectional studies in English that included patients at risk for intra-abdominal adhesions who underwent preoperative ultrasound visceral slide assessment and subsequent intraoperative assessment of adhesions were selected. Two reviewers independently selected 25 articles, extracted data, and assessed bias using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

TABULATION, INTEGRATION, AND RESULTS

Twenty-five articles reported on 1609 patients and 5812 assessed abdominal areas, with considerable heterogeneity of described abdominal areas and degrees of adhesions. Meta-analysis was performed for 21 studies. The periumbilical area was assessed specifically for bowel adhesions in 890 patients in 12 studies, with a 12.0% bowel adhesion rate. Ultrasound assessment for periumbilical bowel adhesions had a combined sensitivity of 95.9% (95% confidence interval, 82.7%-99.1%), specificity of 93.1% (85.1%-96.9%), positive predictive value of 60.4% (44.2%-74.7%), and negative predictive value of 99.2% (97.9%-99.7%) with low heterogeneity (I² = 16%).

CONCLUSION

Visceral slide assessment with ultrasound has a high negative predictive value for the absence of periumbilical bowel adhesions in patients at risk for adhesions and can function as a useful tool to detect adhesion-free areas to allow for safe laparoscopic entry.

Spectrum of CT Findings Related to Bowel Adhesions Without Bowel Obstruction: A Comprehensive Imaging Review

Post-operative adhesions can occur following abdominal or pelvic surgery and are a significant cause of morbidity and mortality. Adhesions are an important cause of abdominal complaints, especially chronic abdominal pain, infertility, and bowel obstruction; responsible for an estimated $2.3 billion annual burden in the United States alone. There is a paucity of literature describing CT findings indicative of the presence of adhesions, however, findings suggestive of this entity may be discovered by a discerning eye. Early recognition and diagnosis may be beneficial for reducing consumption of health-care resources related to abdominal complaints. In addition, these findings may impact surgical planning and facilitate recognition of adhesion-related complications, said to be responsible for a significant number of malpractice claims. The following review discusses various CT findings which may indicate the presence of adhesions. These findings may initially be overlooked, but remain valuable as the clinical presentation evolves to become consistent with adhesive disease. Detection of bowel and peritoneal adhesions can be recognized on imaging modalities based on distortion of bowel loops. This pictorial review illustrates the spectrum of findings related to bowel adhesions encountered on computed tomography imaging.

Clinical course of patients presenting to the emergency department with small bowel obstruction in New York State

INTRODUCTION

Small Bowel Obstruction (SBO) is a common reason for emergency department (ED) visits in the United States. However, little is known regarding the clinical course of these patients. This study aims to identify all patients presenting to the ED in New York State with SBO and follow their clinical course.

METHODS

The New York SPARCS administrative database was used to identify all patients who presented to an ED with the diagnosis of SBO from 2012 to 2014. Patients were followed to identify discharges from the ED, admissions, operations, 30-day readmissions, transfers, and in-hospital death.

RESULTS

Between 2012 and 2014, 43,567 ED visits (events) from 35,646 patients were identified, with 2824 (6.5%) resulting in direct discharge from the ED. A majority (n = 31,193; 71.6%) of ED visits were admitted to the presenting institution without surgery, while 7673 (17.6%) were admitted and underwent surgery. A minority (n = 1947; 4.5%) were transferred to a tertiary center. The overall 30-day readmission rate was 17.9%. Those who underwent surgery were more likely to experience in-hospital death but less likely to have 30-day readmission.

CONCLUSION

To our knowledge, this is the first study that examines the disposition of all patients presenting to the ED with SBO in a large statewide cohort. The majority of admitted patients underwent non-operative management, with overall low rates of readmission, transfer, and in-hospital death.

Can the Laparoscopic Approach for Adhesive Small Bowel Obstruction be Used in Octogenarians? An Observational Study Using ACS NSQIP

BACKGROUND

With the population of octogenarians projected to increase fourfold by 2050, we sought to compare outcomes of laparoscopic versus open approach in octogenarians requiring surgery for adhesive small bowel obstruction (SBO).

METHODS/MATERIALS AND METHODS

Using 2006-2015 American College of Surgeons National Surgical Quality Improvement Project, we identified patients aged ≥80 y who underwent emergency surgery within 1 d of admission for SBO. Risk variables of interest included age, sex, race, body mass index, preoperative sepsis, and American Society of Anesthesiologists (ASA) classification. Outcomes included length of stay, mortality, and pneumonia. Univariable and multivariable analyses were performed.

RESULTS

Eight hundred fifty-six patients were identified. Six hundred ninety-nine (81.7%) underwent laparotomy; 157 (18.3%) underwent laparoscopy. Twenty-four (15.3%) of laparoscopic cases were converted. There was no difference between the open and laparoscopic groups in age, and race, preoperative albumin, or preoperative sepsis. The open group had higher rates of totally dependent functional status, congestive heart failure, chronic obstructive pulmonary disease, and higher ASA class. There was no difference in operative time. Laparoscopy was associated with shorter length of stay. The open approach showed higher rates of postoperative pneumonia, myocardial infarct, and mortality. Multivariable analysis showed increased age, functional status, preoperative albumin, and ASA class associated with mortality. The operative approach was not associated with mortality. Postoperative pneumonia was associated with male sex and open approach.

CONCLUSIONS

Age, preoperative functional status, low preoperative albumin, and ASA classes IV and V were associated with mortality, while the open approach and male sex were associated with postoperative pneumonia. Octogenarians who present with SBO due to adhesive disease may benefit from an initial laparoscopic exploration. Further prospective studies are warranted.

Adhesive small bowel adhesions obstruction: Evolutions in diagnosis, management and prevention

Intra-abdominal adhesions following abdominal surgery represent a major unsolved problem. They are the first cause of small bowel obstruction. Diagnosis is based on clinical evaluation, water-soluble contrast follow-through and computed tomography scan. For patients presenting no signs of strangulation, peritonitis or severe intestinal impairment there is good evidence to support non-operative management. Open surgery is the preferred method for the surgical treatment of adhesive small bowel obstruction, in case of suspected strangulation or after failed conservative management, but laparoscopy is gaining widespread acceptance especially in selected group of patients. "Good" surgical technique and anti-adhesive barriers are the main current concepts of adhesion prevention. We discuss current knowledge in modern diagnosis and evolving strategies for management and prevention that are leading to stratified care for patients.