Acute Small Bowel Research Articles

SUBSTANTIATION OF REAMBERIN APPLICATION IN COMPLEX TREATMENT OF PATIENTS WITH ACUTE SMALL BOWEL OBSTRUCTION

The study evaluated the efficacy of reamberin in complex treatment of patients with acute small bowel obstruction. Methods. The research is based on the results of complex examination of 202 patients with acute small bowel obstruction (ASBO). The patients were hospitalized in Ivano-Frankovsk central municipal clinical hospital at the period from 2009 to 2015. The patients were divided into two groups according to the method of treatment. The complex treatment using common method was applied for the first group of 100 patients with ASBO. The complex treatment using common method and reamberin intravenously (800 ml/day) during 7 days was applied for the second group of 102 patients. Results. The application of reamberin reduced a lot of indices such as leukocytic intoxication, intoxication index, level of middle mass molecule, formation of malonic dialdehyde. The drug stimulated antioxidant system and normalized organ-specific liver enzymes. Conclusions. The application of reamberin is pathogenetically validated in cases of ASBO.

Predictors of Radiation Therapy–Related Gastrointestinal Toxicity From Anal Cancer Dose-Painted Intensity Modulated Radiation Therapy: Secondary Analysis of NRG Oncology RTOG 0529

NRG Oncology RTOG 0529 assessed the feasibility of dose-painted intensity modulated radiation therapy (DP-IMRT) to reduce the acute morbidity of chemoradiation with 5-fluorouracil (5FU) and mitomycin-C (MMC) for T2-4N0-3M0 anal cancer. This secondary analysis was performed to identify patient and treatment factors associated with acute and late gastrointestinal (GI) adverse events (AEs). NRG Oncology RTOG 0529 treatment plans were reviewed to extract dose-volume data for tightly contoured small bowel, loosely contoured anterior pelvic contents (APC), and uninvolved colon outside the target volume (UC). Univariate logistic regression was performed to evaluate association between volumes of each structure receiving doses ≥5 to 60Gy(V5-V60) in 5-Gy increments between patients with and without grade ≥2 acute and late GI AEs, and grade ≥3 acute GI AEs. Additional patient and treatment factors were evaluated in multivariate logistic regression (acute AEs) or Cox proportional hazards models (late AEs). Among 52 evaluable patients, grade ≥2 acute, grade ≥2 late, and grade ≥3 acute GI AEs were observed in 35, 17, and 10 patients, respectively. Trends (P<.05) toward statistically significant associations were observed between grade ≥2 acute GI AEs and small bowel dose (V20-V40), grade ≥2 late GI AEs and APC dose (V60), grade ≥3 acute GI AEs and APC dose (V5-V25), increasing age, tumor size >4cm, and worse Zubrod performance status. Small bowel volumes of 186.0cc, 155.0cc, 41.0cc, and 30.4cc receiving doses greater than 25, 30, 35, and 40Gy, respectively, correlated with increased risk of acute grade ≥2 GI AEs. Acute and late GI AEs from 5FU/MMC chemoradiation using DP-IMRT correlate with radiation dose to the small bowel and APC. Such associations will be incorporated in the dose-volume normal tissue constraint design for future NRG oncology anal cancer studies.

The impact of patient positioning and use of belly board on small bowel toxicity in patients receiving pelvic radiotherapy for gynecological malignancies.

To determine the efficacy of belly board device in patients receiving postoperative radiation for gynecological malignancies in terms of setup error and acute small bowel toxicity. Patients requiring postoperative radiation for gynecological malignancies were prospectively randomized to either treatment with supine position (supine arm) or prone position using belly board (prone arm). Each patient underwent computed tomography simulation in the assigned treatment position, and a three-dimensional conformal radiation was planned. Weekly two to three treatment sessions were verified using portal imaging and setup errors were noted. All patients were reviewed weekly to assess for symptoms and toxicity using a structured format. The systematic and random errors were calculated along the three axes. Twenty-four patients were randomized and 22 patients were available for the final analysis. The systematic error in supine arm versus prone arm was 3.9 versus 3.5 mm, 2.1 versus 4.8 mm and 3.1 versus 3.1 mm along lateral, antero-posterior (AP) and cranio-caudal (CC) direction. The random error in supine arm versus prone arm was 5 versus 3.9 mm, 2.9 mm versus 4.4 mm and 4.3 versus 3.4 mm along lateral, AP and CC direction. The calculated planning target volume margin for supine arm was 1.3, 0.7, and 1.0 cm and margin for prone arm was 1.1, 1.5, and 1.0 cm along lateral, AP, and CC direction, respectively. One patient in supine arm developed Grade 3 toxicity. The systematic error and random error is more along AP direction for prone position. The acute small bowel toxicity was less using belly board.

Use of water-soluble contrast medium (gastrografin) does not decrease the need for operative intervention nor the duration of hospital stay in uncomplicated acute adhesive small bowel obstruction? A multicenter, randomized, clinical trial (Adhesive Small Bowel Obstruction Study) and systematic review

This study evaluated the association between oral gastrografin administration and the need for operative intervention in patients with presumed adhesive small bowel obstruction. Between October 2006 and August 2009, 242 patients with uncomplicated acute adhesive small bowel obstruction were included in a randomized, controlled trial (the Adhesive Small Bowel Obstruction Study, NCT00389116) and allocated to a gastrografin arm or a saline solution arm. The primary end point was the need for operative intervention within 48hours of randomization. The secondary end points were the resection rate, the time interval between the initial computed tomography and operative intervention, the time interval between oral refeeding and discharge, risk factors for the failure of nonoperative management, in-hospital mortality, duration of stay, and recurrence or death after discharge. We performed a systematic review of the literature in order to evaluate the relationship between use of gastrografin as a diagnostic/therapeutic measure, the need for operative intervention, and the duration of stay. In the gastrografin and saline solution arms, the rate of operative intervention was 24% and 20%, respectively, the bowel resection rate was 8% and 4%, the time interval between the initial computed tomography and operative intervention, and the time interval between oral refeeding and discharge were similar in the 2 arms. Only age was identified as a potential risk factor for the failure of nonoperative management. The in-hospital mortality was 2.5%, the duration of stay was 3.8days for patients in the gastrografin arm and 3.5days for those in the saline solution arm (P = .19), and the recurrence rate of adhesive small bowel obstruction was 7%. These results and those of 10 published studies suggest that gastrografin did not decrease either the rate of operative intervention (21% in the saline solution arm vs 26% in the gastrografin arm) or the number of days from the initial computed tomography to discharge (3.5 vs 3.5; P = NS for both). The results of the present study and those of our systematic review suggest that gastrografin administration is of no benefit in patients with adhesive small bowel obstruction.

Pneumatosis Intestinalis in a Patients with Acute Small Bowel Infarction

Pneumatosis Intestinalis in a Patients with Acute Small Bowel Infarction

Ileo-ovarian knotting in a case of strangulated inguinal hernia in a 46-year-old female: A first case report

Ileo-ovarian knotting in a case of strangulated inguinal hernia, reported herein, has never been reported before. We believe this case is of great importance because of its absolute rarity. A 46-year-old female came with right inguinal swelling, vomiting, and abdominal distension for 2 years but aggravated during the last week. She had passed stools 24 h ago and was vomiting since then. The abdomen was distended as well as tenderness and guarding was noted in the lower abdomen. Examination revealed strangulated right inguinal hernia with abdominal X-ray suggestive of acute small bowel obstruction. Abdominal ultrasonography revealed dilated small bowel loops and aperistaltic edematous intestines in the right inguinal region; an urgent surgery was, hence, planned. Exploration revealed ileo-ovarian knotting with one-foot gangrene of small bowel and strangulated right ovary. Resection of the right ovary, bowel resection, and end-to-end anastomosis with hernioplasty were performed. The patient recovered well in the postoperative period.

Microelemental homeostasis correction of and oxidative stress in patients with acute intestinal obstruction

To improve the results of treatment of patients with acute small bowel obstruction. The research is based on the results of a comprehensive survey 202 people with acute small bowel obstruction. Reamberin was used in 102 patients treatment. It was established that metalloenzymes take an active part in the formation of endotoxemia in people with acute small bowel obstruction. Also, in patients as a result of an imbalance between oxidant and antioxidant systems, accumulated a significant amount of lipid peroxidation products, along with it a decrease activity of enzymes of antioxidant system. reamberin application in complex treatment of acute small bowel obstruction provided the reduction in the time correction of oxidative stress by preventing the growth and activity of lipid peroxidation products with simultaneous stimulation of the antioxidant system and contributed to the normalization of microelement homeostasis.

Internal hernia - a rare cause of small bowel obstruction: a case report

Internal hernia means a protrusion into pouches or openings in the peritoneum or mesentry in contrast to the hernias through defects in the retaining walls of the abdomen. Internal hernias are of many varieties with different classifications and can be congenital or acquired post-surgery. We present a case of a 55 year old female who presented with symptoms of acute small bowel obstruction with previous history of exploratory laparotomy 20 years back for reasons not known to her. Routine blood investigations, chest and abdomen skiagram and a CECT abdomen were performed (which gave no significant clue to diagnosis) and after a failed conservative trial patient was taken for exploration. Intra operatively a gangrenous loop of small bowel was found herniating through a band between the small bowel mesentry and the sigmoid mesocolon, forming a closed loop obstruction. Resection anastomosis of the gangrenous segment along with band transection was performed. The post-operative course was uneventful. Internal herniation as a cause of bowel obstruction should always be kept in mind as a differential.

MDCT signs predicting internal hernia and strangulation in patients presented to emergency department with acute small bowel obstruction

ObjectiveWe prospectively evaluate multidetector computed tomography (MDCT) criteria of internal hernia, and related complication as intestinal strangulation. Methods27 patients presented to emergency department with acute small bowel obstruction (ASBO) and diagnosed with MDCT as IH were included. Validity of different MDCT criteria in diagnosing IH was compared with surgical diagnosis. ResultsSurgical diagnosis was 22 patients with IH (14 paraduodenal and 8 transmesenteric hernia) and 5 false positive cases. There was excellent agreement between MDCT and surgery in diagnosing paraduodenal hernia (k=1), and good agreement in diagnosing transmesenteric hernia (k=0.624). Significant MDCT criteria include the following: cluster of small-bowel (p<0.0001); mass effect to surrounding (p=0.009); crowding of mesenteric vessels (Swirl's sign) (p=0.01). Sensitivity, specificity, PPV, NPV and accuracy of MDCT in diagnosing strangulation were 83%, 100%, 100%, 95%, and 96% respectively. MDCT signs for detecting strangulation were statistically significant and varied from highly significant for bowel-wall thickening and mesenteric vessel engorgement (p<0.001) to significant for abnormal bowel-wall enhancement, mesenteric infiltrate and mesenteric fluid with p value=0.001. ConclusionMDCT helps in early diagnosis of IH and strangulation, which accounts for appropriate management of such emergent cases.

Meckelʼs Diverticulum: Thinking Outside the Box with Acute Massive Small Bowel Hemorrhage in an Adult

Introduction: Nonvariceal upper GI bleeding remains a common GI emergency with an incidence of 37-172 cases per 100,000 adults and a mortality rate of 3-14%.1 Meckel's diverticulum, while well described in the pediatric population, is a rare source of bleeding in adults that requires a different diagnostic and treatment approach. Case Report: We report a thirty year old woman with a history of IBS who presented to the emergency department two hours after having two episodes of melena and a subsequent episode of syncope. On arrival, she had stable vital signs but a hemoglobin level of 9.7 g/dl. Initial work-up included an EGD that was normal and a colonoscopy that showed clotted blood throughout the colon but fresh red blood in the terminal ileum. A radionuclide bleeding study the next day was negative. One day later, patient had recurrent bleeding. Repeat radionuclide study was positive in the right lower quadrant, thought to represent a small bowel source. At that point, despite having required 6 units of blood, patient remained hemodynamically stabile. Decision was to hold on angiography and instead pursue a Meckel's scan. Unfortunately, this scan was delayed one day due to interference between the radionuclide and technetium pertechnetate, but the next day the scan was done and was positive. The patient was then taken for surgery the same day and had an uncomplicated resection of the Meckel's diverticulum that was confirmed on pathology. Discussion: In up to 5% of cases of GI bleeding, the source is not found.2 Meckel's diverticulum, while commonly encountered in the pediatric population, remains a rare diagnosis for adults. Other diagnostic tests after negative endoscopies, including video capsule endoscopy, angiography, and radionuclide study are less sensitive and specific than a Meckel's scan and can interfere with making a timely diagnosis; indeed our use of the radionuclide study delayed the diagnosis by 1 day. This case illustrates the importance of keeping Meckel's in the differential diagnosis and the impact of appropriate testing in early diagnosis.

Optimal Timing of Small Bowel Capsule Endoscopy in Acute Small Bowel Bleeding: A Meta-Analysis

Introduction: Small Bowel GI bleed constitutes 5% of all GI bleeding. Small bowel capsule endoscopy (SBCE) is recommended after negative pan endoscopy. The optimal timing of the SBCE to achieve the highest diagnostic yield is not known with most studies recommending early studies. Methods: This ia a meta-analysis of current studies on timing of SBCE in acute small bowel bleed. PubMed, Google Scholar, CIHNAL, Scopus and Web of Science were Searched for articles on studies that evaluated diagnostic yield of SBCE based on inpatient/outpatient status and/or timing of SBCE from last bleed or admission. Data extracted were sorted into timing categories and pooled result in form of Odd ratio of the diagnostic yield for P2 lesion, or significant lesions and active bleeding comparing earlier to later timing. Heterogeneity, sensitivity analysis and publication bias were assessed for each category. Results: Ten studies were included in the final analysis with a total number of 1069 patients. Five of these studies were used for multiple timing categories. Measure of heterogeneity I2 for all studies was 0-45%. Fixed effect model was used for all analysis. The pooled Odd ratio (OR) for finding a lesion or active bleeding in patients with acute small bowel bleeding who had inpatient SBCE compared to those who had outpatient SBCE was 1.588 (95% CI 1.078-2.339, p value =0.019). For the 2 day category, OR was 3.515( CI 95%1.095-11.289 p value =0.035). For the 3days category OR was 1.87 (95% CI 1.2-2.9 p value =0.006). For the 5 day group, OR was 3.25 (95% CI 1.142-9.262 p value = 0.027). For the 7 day 10 day, 14 day and 15 day groups, there was only one study in each category. OR for 7 days, 4.96 (95% CI 1.769-13.93 p value =0.002), 10 days 56( 95% CI 4.36 -719 p value =0.002) 14 days, 4.091( 1.417-11.814 p value =0.009) and 15 days 18.46(95% CI 4.58-74.43 p value =0.001). Funnel plot was visually symmetrical in all studies but there was evidence of publication bias in the inpatient/outpatient group using Eggers regression model. Conclusion: This meta-analysis suggests that SBCE done in the inpatient setting has a higher diagnostic yield compared to procedures done in the outpatient setting. There was however, evidence of publication bias in this group. In all categories, earlier studies had higher diagnostic yield. A 2 day cut off had a higher OR than 3 day. The diagnostic yield up to 15 days was still significant and recommended for outpatient setting.Figure 1Figure 2Figure 3

MDCT Diagnosis of Symptomatic Incarceration of the Right Ileocecocolic Mesentery Within a Complete 360-Degree Whirl of the Great Omentum: Follow the Vessels!

Case Report A 74-year-old female was referred to the emergency department with persistent abdominal pain. Five months earlier, she had experienced acute small bowel intestinal obstruction necessitating emergency laparotomy. This occlusion was caused by anterior parietal adherences related to recurrent previous abdominal surgery. Contrast-enhanced MDCT excluded now significant dilatation of the gut but demonstrated an unusual accumulation of abdominal fat incarcerating mesenteric vessels and bowel segments in the midline of the anterior mesogastrium (Figure 1, white arrows). Careful multiplanar analysis (Figure 2A, B, C shows the antero-posterior coronal MPR views, and Figure 2D shows the axial oblique MPR view) revealed the omental nature of the encircling fatty structure through the clear delineation of the encircling omental vessels (white arrows). This 360-degree whirl of the greater omentum was incarcerating the right ileocecocolic mesenteric vessels (white star); the two incarcerated and compressed bowel segments were identified as the terminal ileum and the transverse colon (black arrows). Selective volume-rendering reconstruction confirmed the whirl (Figure 3). Despite the fact that there was no critical dilatation nor suffering signs of the gut at the time of MDCT, the risk of occlusion was nevertheless considered important, and it seemed unlikely that this complete omental whirl would resolve spontaneously. This caution justified laparotomy.

Diffuse Large B-Cell Lymphoma Complicated by Small Bowel Obstruction after Radiotherapy: a Case Study

ABSTRACT Although the spleen is frequently involved in disseminated non-Hodgkin’s lymphoma (NHL), splenic presentation as the initial or only site of disease is uncommon. Treatment modalities include surgery, chemotherapy, and radiation therapy. The priority of cancer follow up is to perform surveillance for recurrent cancer and evaluation of treatment response. Side effects of treatment are frequently missed or overlooked. A 66-year-old woman was presented to our hospital with a month history of spleen enlargement. On physical examination the spleen was palpated at Schuffner 2. Abdominal MSCT scan was suggestive of lymphoma. Surgery revealed adhesion and obstruction of the stomach. Biopsy and gastrojejunostomy shunting were done, but splenectomy was difficult. The pathology anatomy findings confirmed the diagnosis of diffuse non Hodgkin’s lymphoma large B-cell type. Immunohistochemistry showed positive CD3 and CD20. She underwent 6 cycles of rituximab, cyclophosphamide, adriamycin, vincristine, and prednisolone (RCHOP) chemotherapy. CT evaluation done 7 months later revealed that the hilus lienalis lymph nodes and spleen has decrease in size. However, a lumbosacral x-ray done due to back pain revealed metastasis on her 1st and 2nd lumbal spine. After a single fraction of radiotherapy, nausea, vomiting and abdominal distension occurred. A 3 position abdominal x-ray revealed signs of small bowel obstruction. After surgery she has received 9 cycles of zoledronic acid and remained in good condition and ambulatory. Splenic presentation as the initial or only site of non-Hodgkin’s lymphoma (NHL) is uncommon. Acute small bowel obstruction and fistula due to palliative radiation therapy for bone metastasis needs prompt and appropriate treatment.

Outcomes of laparoscopic management of acute small bowel obstruction: a 7-year experience of 110 consecutive cases with various etiologies.

Laparoscopic surgery is emerging as an alternative to open surgery for treating acute small bowel obstruction (SBO). While postoperative adhesion is the most frequent etiology, the optimum treatment for all types of SBO needs to be evaluated. A retrospective review was performed of 110 consecutive patients who underwent laparoscopic surgery at our institution between 2009 and 2015. The short-term outcomes included perioperative factors, while the long-term outcome included the recurrence rate. Of the 110 patients, 55 were female. The median age at surgery was 69.5years. Laparoscopic surgery was completed in 91.8%. The median operative time was 82min, median amount of bleeding was 0ml, and median postoperative hospital stay was 8days. Intraoperative major organ injury was seen in 2.7%. The complication rate (Clavien-Dindo≥class II) was 8.2%, and the mortality rate was 3.6%. The recurrence rate was 8.2%. Only dense and matted adhesion was a predictive factor for conversion (OR 30.244). Good short-term outcomes and feasible long-term outcomes were achieved with a laparoscopic approach to treating acute SBO. It was a safe and effective method, especially in patients with isolated bands, simple enteral angulation, and foreign body or tumor, while dense and matted adhesions were still challenging.

Laparoscopic Intervention for Cases of Adhesive Small Bowel Obstruction: Is It Safe and Beneficial?

Objective: The objective of the study was to evaluate the safety and benefit of laparoscopic management of adhesive small bowel obstruction in order to establish an optimal operative strategy for those patients. Methods: Between April 2012 to September 2014, our study included 56 patients who presented with acute adhesive small bowel obstruction required surgical intervention. We performed laparoscopy for all patients and performed laparoscopic adhesiolysis whenever possible (LAP Group). Otherwise we converted to open surgery (CONV Group) and we compared the outcome of the two groups and evaluated the risk and benefit of initial laparoscopy. Results: 56 patients were enrolled in this study. Laparoscopic techniques (LAP) alone were successfully used to complete 40 cases (73%). Sixteen patients (28%) were converted to open surgery through midline laparotomies. A single band was identified in 38 patients. Complications were comparable between the two groups however the laparoscopic cases benefited from shorter operative times, fewer wound complications (infection/hernia), quicker recovery, shorter hospital stay, and less pain. Conclusion: Laparoscopy has a valuable role for cases presented with adhesive small bowel obstruction, specifically for those patients with a postoperative single band causing obstruction. So, most patients with adhesive intestinal obstruction are candidates for laparoscopy. A significant number of patients will be spared a large laparotomy incision.

The feasibility of laparoscopic management of incarcerated obturator hernia.

Obturator hernia (OH), a rare cause of acute small bowel obstruction, requires immediate surgical intervention to prevent serious complications and mortality. We assessed the safety and efficacy of laparoscopic surgery in patients with incarcerated OH presenting with acute abdomen in an emergency setting. Data pertaining to patients diagnosed with incarcerated OH between 2011 and April 2015 at our hospital were reviewed. Patients' characteristics, operation details and postoperative outcomes were retrospectively analyzed. All ten patients diagnosed with incarcerated obturator hernia during the reference period were females (average age 72.1±11.8years; average weight 44.1±6.9kg; average body mass index 17.8±2.1kg/m2; average operating time 63±15min; average hospital stay 6.2±6.6days). Twelve occult hernias, including six contralateral OHs, two ipsilateral femoral hernias and two bilateral femoral hernias were detected in six patients (60%), which were simultaneously repaired after laparoscopic exploration. Nine patients (90%) were successfully treated with synthetic mesh by laparoscopic technique. Only one case required intraoperative conversion to open surgery due to strangulated intestine with perforation. Wound infection was reported in one patient who had undergone bowel resection, but with an eventual complete recovery. Postoperative period was uneventful in the other nine patients. No recurrence or complications were reported on follow-up (mean duration of follow-up: 6-54months). In this study, laparoscopic technique was associated with a reduced duration of hospital stay and fewer complications. In addition to being a safe and minimally invasive strategy, it allowed for simultaneous diagnosis and treatment of occult hernias during the same procedure. The approach may be a better option for the treatment of incarcerated OH and occult hernias in selected patients.

Indications for the laparoscopic approach to acute small bowel obstruction: A retrospective review of 50 cases, a literature review, and a single hospital's preliminary experience.

Small bowel obstruction (SBO) is mainly caused by postoperative adhesions, but a broad spectrum of diseases may cause this pathogenetic condition. Laparoscopic treatment represents an efficient approach to SBO. The aim of this paper was to review a single center's experience with a minimally invasive approach to multiple pathologic scenarios causing SBO. From January 2010 to December 2012, 50 consecutive patients underwent laparoscopic surgery for mechanical SBO. In 90% of patients, the surgical procedure was totally laparoscopic, while 10% required conversion to midline laparotomy. In-hospital morbidity was 15% among totally laparoscopic patients and 40% among those who underwent conversion to midline laparotomy. Thirty-day mortality was zero. One patient died 4 months postoperatively from neoplastic disease progression; the remaining patients were free from occlusive symptoms at follow-up. The minimally invasive technique applies to a broad spectrum of cases. A larger cohort of patients seems necessary to reproduce our results and confirm the effectiveness of a laparoscopic approach to SBO.

Acute small bowel obstruction due to Meckel's diverticulum: An unusual presentation

Majority of the persons with Meckel’s diverticulum are asymptomatic throughout life. In the symptomatic adults, small bowel obstruction is the most common presentation. The common mechanisms of small bowel obstruction include intussusception, and volvulus around fibrous bands adherent to the umbilicus. A patient with acute closed loop obstructionand strangulation of small bowel due to Meckel’s diverticulum by a rare mechanism is described. The signs of closed loop obstruction and importance of evaluating the signs of strangulation in a patient with closed loop small bowel obstruction are emphasized here. Keywords:Meckel’s diverticulum; closed loop obstruction; bowel strangulation; acute intestinal obstruction

Virtual monoenergetic reconstruction of contrast-enhanced dual energy CT at 70 keV maximizes mural enhancement in acute small bowel obstruction

PurposeIn patients with small bowel obstruction (SBO), it is challenging to detect early ischemia. The purpose of this study is to evaluate the quantitative and qualitative benefits of virtual monoenergetic image (VMI) reconstruction in the assessment of small bowel mural enhancement on dual source dual energy computed tomography (CT) scans of the abdomen. Materials and methodsInstitutional review board approval was obtained, for this retrospective analysis. 72 consecutive patients with acute SBO were scanned using a second generation 128-slice dual source, CT system. Images were reconstructed at VMI energy levels from 40 to 110keV in 10keV increments and were analysed quantitatively and qualitatively. Contrast to noise ratios (CNR) and signal to noise ratios (SNR) for mural enhancement were recorded for all VMI datasets and compared to conventional polychromatic images (PCI) at 120kVp. Subjective analysis of mural enhancement on VMI and PCI was performed by 3 blinded readers. ResultsOptimal CNR values for small intestinal mural enhancement were observed at 70keV. Qualitative assessment revealed that there was no statistical difference in diagnostic accuracy between VMI and PCI. All readers reported improved confidence when assessing the contrast enhancement on the 70keV VMI dataset and in our series, 2 additional cases of ischemia were identified on this reconstruction. ConclusionContrast-enhanced dual source dual energy CT with VMI reconstruction at 70keV maximizes the CNR of small bowel mural enhancement and increases the overall diagnostic confidence in assessing mural enhancement in patients with SBO.

DEVELOPMENT OF A METHOD FOR ADAPTING THE SIZE OF LAPAROTOMY TO TOPOGRAPHIC-ANATOMICAL PARAMETERS OF THE ABDOMEN OF PATIENTS WITH SMALL BOWEL OBSTRUCTION

Background: Optimization of the size of the surgical access exerts a positive effect on recovery dynamics. The size of median laparotomy in operations for small bowel obstruction is usually determined without consideration of specifics of the abdominal cavity anatomy of the patient. Aim: To improve the results of treatment of patients with acute small bowel obstruction by adapting the parameters of the median laparotomy to constitutional characteristics of the patient. Materials and methods: The results of treatment of 101 patients with acute small bowel obstruction were analyzed. In 49 patients of the group I, laparotomy was performed with the newly developed method to determine the size of laparotomy. Fifty two patients of the group II were treated at the time when the method was still in the process of development. To identify optimal parameters of the laparotomy, we performed anatomical experiments in 90 cadavers with dolicho-, mesoand brachymorphic constitution. Results: During the anatomical experiments, we found that in individuals with dolychomorphic constitution, the average depth of the abdominal cavity amounted to 58.07% of the distance between the upper anterior iliac spines, in those with mesomorphic body build, this parameter was 42%, and in individuals with brachymorphic constitution, 37.67% of this distance. Based on the analysis of surgical accessibility parameters, we found that the optimal length of median laparotomy in individuals with dolichomorphic body build was 63.877% of the distance between the front upper iliac spines, in mesomorphic ones, 46.2%, and in brachymorphic, 41.437% of this distance. The described method of determination of the surgical incision length was applied in 49 patients from the group I. The average size of laparotomic incision was 121.74 ± 10.4 mm. The use of the proposed method for determination of the length of surgical incision allowed for reduction of the mean duration of hospitalization from 13.32 ± 3.4 to 10.02 ± 2.1 hospital days. On average, patients from group I could defecate without stimulation one day earlier than those from group II, with abdominal pain intensity being much lower. Conclusion: A differentiated approach to laparotomy depending on the constitution of a patient with acute small bowel obstruction allows to reduce operational trauma and improve the recovery dynamics.