Adhesional Small Bowel Obstruction Research Articles

A three-year retrospective analysis of variables and their relationships as outcome indicators following emergency laparotomies in octogenarians: insights from a single institutional experience

Background: This retrospective study aims to specifically assess the morbidity and mortality outcomes linked to emergency laparotomies in a subset of patients aged 80 years and above, referred to as octogenarians. The objective is to gain insights into the specific challenges and outcomes faced by this elderly population undergoing emergency laparotomies. Methods: This retrospective analysis focused on emergency laparotomies in octogenarians between June 2020 and June 2023, involving 62 cases out of 370 total emergency laparotomies conducted across various age groups. Using a standardized proforma, data was collected, and statistical analysis was performed with statistical package for the social sciences (SPSS). Results: In this study involving 62 elderly patients (mean age 84) undergoing emergency laparotomies, common diagnoses included adhesional small bowel obstruction (32.3%)and large bowel obstruction due to diverticular disease (21.0%). Approximately 22.6% of cases were malignant, emphasizing the diverse nature of the cohort. A significant portion (56.5%) underwent bowel resection, and 16.1% had a stoma. Notably, 100% of patients were not seen by geriatrics, indicating potential gaps in comprehensive assessment despite the absence of geriatrician involvement, the overall mortality rate was 21%, emphasizing the potential impact of geriatrician reviews. Conclusions: In summary, emergency major abdominal surgery poses significant risks, particularly for frail and elderly individuals with multiple co-morbidities. Recognizing frailty as an independent risk factor is crucial and highlights areas of potential improvement in this area with early involvement of geriatricians.

905 To Operate or Not to Operate? a Clinical Audit in the Management of Adhesional Small Bowel Obstruction

Abstract Aim To compare our current management of adhesional small bowel obstruction (ASBO) with the National audit for small bowel obstruction 2017 and Bologna guidelines, to produce a flow chart which will indicate:First line management should be with intravenous fluids, analgesia, anti-emetics, and nasogastric tube (NGT).Patients diagnosed with ASBO should first undergo a trial conservative management with a water-soluble contrast.Operative management should be considered after 72 hours of non-resolving SBO. Method The medical records of all SBO patients admitted to Ipswich Hospital NHS trust between 1/4/2020 and 1/4/2021 were screened. All patients above 16 years of age and with a clinical diagnosis of ASBO were included in the audit. Results 43 patients were diagnosed with ASBO.All patients were prescribed IV fluids. 38 (88.4%)and 36 patients (83.7%)received analgesia and anti-emetics respectively.21 patients(72.1%) had a NG tube inserted.24 patients (53.5%) were treated conservatively while 19 patients were taken to theater.37% of the ASBO patients, who were managed conservatively, were given a water-soluble contrast(Gastrograffin),which caused resolution of the obstruction in 20 patients(83.3%),while the rest were taken to theater.The average time to theater was 4 days(96 hours). Conclusions Our results are in line with the comparing standards. Our first line management for ASBO could be improved.The use of a water-soluble contrast should be used more regurarly in the conservative management of ASBO. A step-by-step ASBO flow chart could help the admitting surgical team follow the appropriate steps for the better management of ASBO.

SP5.8 Laparoscopy for small bowel obstruction improves outcomes

Abstract Aims Adhesional small bowel obstruction is the commonest cause of emergency general surgery. Fewer than 20% of cases are started laparoscopically, but there is huge variability across the country from 80% in some units to 0% in others. This study examines whether the laparoscopic approach reduces length of stay and mortality. Methods The national NELA database was interrogated to identify patients operated for small bowel obstruction due to adhesions. Post-operative length of stay and mortality were analysed according to surgical approach. Results 20,597 patients with small bowel obstruction due to adhesions were identified; overall 30-day mortality was 6.2%. 3870 of these 20,597 cases (18.5%) were started laparoscopically. Mortality in this group was 3.2% compared with 7.0% in the laparotomy group. This association was also demonstrated in patients with predicted mortality <5% (0.9% v 1.4%) and with predicted mortality <10% (1.6% v 2.5%). In the laparoscopic group, more patients were discharged within 3 days (23% v 3%) and within 7 days (58% v 34%) compared to the laparotomy group. When surgery could be completed laparoscopically, all of these associations became stronger – mortality in this group was 1.9%, and 40% of patients were discharged within 3 days. Conclusions The laparoscopic approach to adhesional small bowel obstruction is safe and effective, and is associated with shorter length of stay and reduced mortality. The association holds even in patients converted to open surgery, and is not dependent on patient selection. Laparoscopy should be the approach of choice for adhesional small bowel obstruction.

ThTP5.7 Laparoscopic Management of Adhesional Small Bowel Obstruction: Is it Feasible?

Abstract Despite advances in laparoscopic surgery, there is limited evidence on its application and outcomes for the management of adhesional small bowel obstruction(aSBO). Literature defines indications for surgery, without addressing the appropriate approach, traditionally involving laparotomy. This study investigated the feasibility of laparoscopic adhesiolysis for aSBO. This retrospective cohort study included electronic data of patients admitted with aSBO, in a large laparoscopic centre over 3 years. Exclusion criteria applied to non-adhesional SBO, large bowel pathology and conservative treatment. Outcomes included the rate and reason for conversion to laparotomy, complications and length of stay (LOS). 85 patients with CT proven aSBO were included, over 3 years. 69(81.2%) of patients were approached laparoscopically and there was a 32%rate of conversion to laparotomy, due to technical difficulty(54.6%), planned “laparoscopy-first”(22.7%) or intraoperative emergency(18.2%).Those managed laparoscopically had 5 days median LOS compared to 9 in the converted subgroup. Operation note review, revealed a standard operative approach using naso-gastric tube, right sided ports, and collapsed small bowel manipulation to identify the adhesion point. Enterotomy rate was 13.0% and 14.5%of patients required bowel resection from an extraction site. Post-operatively, 20.3%of patients suffered prolonged ileus, 5.8%anastomotic leak, 5.8%required re-operation, 8.7%were readmitted with recurrence and there were 10(14.5%) in-hospital deaths. Our study indicated that laparoscopic adhesiolysis could be feasible for selected patients, with a CT proven transition point. Given the observational findings of this single centre study, further research in laparoscopic units is required, including direct comparison with laparotomy, and converted subgroups, aiming to generate standardised guidelines for the laparoscopic management of aSBO.

SP1.11 Hospitals offering emergency laparoscopic surgery have improved outcomes

Abstract Aims Only 20% of patients requiring emergency surgery in the UK are offered laparoscopic surgery; there is wide variability in uptake of laparoscopic emergency surgery between hospitals, ranging from 0% to over 80% of cases. This study investigated whether hospitals with an advanced laparoscopic culture had improved outcomes. Methods The national NELA database was interrogated to identify patients requiring surgery for adhesional small bowel obstruction; this was selected because it is common (around 25% of cases in NELA) and often amenable to laparoscopic surgery. Hospitals were grouped into quintiles, according to the number of cases attempted by the laparoscopic approach; each group was assessed for length of stay and mortality. Results In 176 acute hospitals, 20597 operations were performed for adhesional SBO. Overall mortality was 6.2%. In the quintile with the lowest rate of laparoscopy, 4% of cases were started laparoscopically, compared with 44% in the highest quintile. In the lowest quintile, 4.8% of patients were discharged within 3 days, compared to 13.8% in the highest quintile; discharge at 7 days was 26% versus 37%. Overall, 30-day mortality in the group with the lowest rate of laparoscopy was 6.9%, compared with 5.4% in hospitals with the highest rate of laparoscopy (p<0.001). Conclusions Hospitals where patients with adhesional SBO are offered laparoscopic emergency surgery demonstrate shorter lengths of stay and a significantly reduced mortality. This may be due to the benefits of the laparoscopic approach; it could also be a surrogate marker for an advanced culture of emergency surgery.

Compliance on the use of water-soluble contrast agent in adhesional small bowel obstruction

Objectives: Small bowel obstruction is associated with significant morbidity and mortality. This study aimed to map outcomes of patients admitted with adhesional small bowel obstruction (ASBO ) with a view evaluating the effectiveness of water-soluble contrast agents (WSCA). Materials and Methods: A retrospective review of all emergency admissions coded for operative and non-operative treatment of small bowel obstruction between January 2018 and June 2020. Electronic patient records were utilized to confirm cases of ASBO. Patient demographics, hospital administrative data, treatment and surgery-related data are collected. Results: A total of 110 patients were admitted with ASBO initiated with conservative management. Median time to computed tomography (CT) scan was 12 h (Range: 3–115 h). Oral contrast was administered in only 11%; of these, 58% (7/12) resolved spontaneously compared to 52% (51/98) in those without contrast. About 43% (47/110) of all patients necessitated surgical intervention. Median time from admission to surgery was 43.5 h (Range: 10– 288 h). There were one 30-day re-admissions in patients surgically managed compared to two in those conservatively managed. Conclusion: Early CT scan facilitates initiation of non-operative management in stable patients with ASBO. In this series, the scant use of WSCA despite international guidelines did not compromise patient outcomes or length of stay.

Neutrophil-lymphocyte ratio and platelet-lymphocyte ratio use in detecting bowel ischaemia in adhesional small bowel obstruction.

Bowel ischaemia significantly increases morbidity and mortality from adhesional small bowel obstruction. Current biomarkers and clinical parameters have poor predictive value for ischaemia. Our study investigated whether neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) could be used to predict bowel ischaemia in adhesional small bowel obstruction. This single-centre retrospective study collected clinical, biochemical and radiological data from patients with adhesional small bowel obstruction between 2017 and 2020 who underwent operative management. The presence or absence of bowel ischaemia/infarction was used to distinguish two populations. Biochemical markers on admission and immediately prior to operation were collected to give platelet-lymphocyte ratio (PLR0 and PLRPRE-OP , respectively) and neutrophil-lymphocyte ratio (NLR0 and NLRPRE-OP , respectively). SAS 9.4 (SAS Institute Inc., Cary, NC) software was used for data analysis with Mann-Whitney U testing for continuous variables and Pearson Chi-square test for categorical variables. Sensitivity and specificity for PLR and NLR were calculated by means of receiver operating characteristic (ROC) curve analysis. Twenty-seven patients had intra-operative bowel ischaemia whilst the remaining 73 had no evidence of bowel ischaemia. Both median PLRPRE-OP and NLRPRE-OP were significantly higher in patients with bowel ischaemia compared to those without (PLRPRE-OP 272 [IQR 224-433] and 231 [IQR 146-295] respectively, P=0.027; NLRPRE-OP 12.5 [IQR 8.6-21.3] v. 5.5 [IQR 3.5-10.2] respectively, P ≤ 0.001). Area under the receiver operator characteristic curve (AUC) was 0.762 for NLRPRE-OP , with a sensitivity of 85.1% and specificity of 63% for NLR 7.4. Raised NLR is predictive of bowel ischaemia in patients with adhesional small bowel obstruction.

446 Efficacy of Early Gastrografin Use in Adhesional Small Bowel Obstruction

Abstract Aim The aim of this audit was to establish the outcomes in patients who receive gastrografin versus patients who do not receive gastrografin in patients with adhesional small bowel obstruction (SBO). Method This was a retrospective data collection of patients admitted with “small bowel obstruction” between June and September 2021. Further patient selection criteria were applied. Data was collected using the EPR system and assimilated using Excel spreadsheet. Results A total of 76 patients with SBO were identified. 32 patients were diagnosed with adhesional SBO. Of these, 21/32 had previous maximally invasive surgery, 7/32 has previous minimally invasive surgery, and 4/32 had no previous surgery. 17/32 patients received gastrografin, of which 15 resolved and 2 needed surgery (1×laparoscopic adhesiolysis and 1×laparotomy). Average length of stay in patients who received gastrografin was 4.2 days. 15/32 patients did not receive gastrografin, of which 6 resolved and 9 needed surgery (7×laprascopic adhesiolysis and 2×laparotomy). Average length of stay in patients who did not receive gastrografin was 10.3 days. Conclusions Early use of gastrografin in stable patients with adhesional SBO appears to have good outcomes and should be considered after discussion with senior clinicans. Patients who are septic, severely tender on examination or who show signs of ischaemia should not have surgery delayed. Formal standard operating procedures (SOP) should be developed for the management of adhesional SBO.

812 Evaluating the Impact of Surgical Subspecialisation on Patient Outcomes Following Adhesional Small Bowel Obstruction

Abstract Aim Small bowel obstruction (SBO) is the most common indication for laparotomy in the UK. While general surgeons have become increasingly subspecialised in their elective practice, emergency admissions frequently remain undifferentiated. This study aimed to assess temporal trends in the management of adhesional SBO and explore the influence of subspecialisation. Method Data was collected for patients admitted acutely with SBO across Northern England between 01/01/02 and 31/12/16, including demographics, co-morbidities and procedures performed. Patients were excluded if a non-adhesional cause was identified and were grouped by the responsible consultant's subspecialty. The primary outcome of interest was 30-day inpatient mortality. Results 2818 patients were admitted with adhesional SBO during a 15-year period. There was a consistent female preponderance (55.9%), while age and comorbidity increased significantly over time (both p<0.001). The proportion treated conservatively decreased (47.1% vs. 40.4%, p=0.009), as did the time to operation (median 2 vs. 1 day, p<0.001). There was an increased propensity for patients to be managed by gastrointestinal (colorectal & upper gastrointestinal) subspecialists (69.9% vs 51.6%, p<0.001). While a trend towards laparoscopy was evident (p=0.005), particularly amongst gastrointestinal subspecialists, uptake remained limited. Length of stay (p<0.001) and 30-day mortality (p<0.001) have improved over time, with the best outcomes seen in colorectal (2.6%) and vascular subspecialists (2.4%). However, following adjustment for confounding variables, consultant subspecialty was not a predictor of mortality. Conclusions Outcomes following adhesional SBO have improved despite the increasing burden of age and co-morbidity. While gastrointestinal subspecialists are increasingly responsible for their care, mortality is not influenced by consultant subspecialty.

Anticholinergics Stop the Pain and the Motions – A Lesson for Surgeons

Background: Small bowel obstruction commonly presents to surgeons acutely. Adhesions and hernias are the commonest causes. However, medical ileus and gastroparesis are often overlooked. Case report: This article presents a case of an 82year-old woman on orthopaedic ward referred to the general surgeons with symptoms of small bowel obstruction: bilious vomiting and abdominal distension. Despite all conservative measures, symptoms did not improve. Oral contrast on cross-sectional imaging and gastrograffin follow-through consistently illustrated a transition point at the base of jejunum. No mass or mural lesion was seen. The patient was prescribed regular orphenadrine for cramps over her right periprosthetic femoral fracture. Surgical intervention was then considered on suspicion of adhesional small bowel obstruction. A day before the planned laparotomy, the general surgical team stopped orphenadrine as the last attempt to relieve her symptoms. Ceasing orphenadrine reversed her obstructive symptoms and signs within hours. Conclusion: Orphenadrine has a broad range of anticholinergic effects that is known to cause gastroparesis and ileus, which is often overlooked. This article discusses the learning points of this case and reviews literature regarding its pharmacologic effects.

NELA.01The Impact of Laparoscopy on Emergency Surgery for Adhesional Small Bowel Obstruction: Prospective Single Centre Cohort Study

Abstract Aims Laparoscopic adhesiolysis is being increasingly used to treat adhesional small bowel obstruction (ASBO). However, concerns regarding iatrogenic bowel injury and failure to relieve the obstruction have limited its uptake. This study reports our centre’s experience of adopting laparoscopy as the standard operative approach for ASBO. Methods A single centre prospective cohort study was performed incorporating local data from the National Emergency Laparotomy Audit Database; 01/01/2015-31/12/2019. All patients undergoing surgery for ASBO were included. Patient demographic, operative and in-hospital outcome data were compared between different surgical approaches. Linear regression analysis was performed for length of stay. Results Of 299 cases, 76.3% were started laparoscopically and 52.2% successfully completed. Rates of attempted laparoscopy increased over the 5 year period. Patients treated laparoscopically had lower P-POSSUM-mortality (2.1 vs 5.7%, p = <0.001), shorter post-operative LOS (4.2 vs 11.3 days, p = 0.000) and lower in-hospital mortality (2 vs 7 deaths, p = <0.001). In regression analysis, laparoscopy had the strongest association with post-operative LOS ( 8.51, p = 0.002). Conclusion Laparoscopy is a safe and feasible approach for adhesiolysis in the majority of patients with ASBO. It is now the standard approach in our centre, with 83.3% of cases started laparoscopically in 2019. It is associated with reduced post-operative length of stay with no impact on complications or mortality. This challenges the widely held view that laparoscopy should be for selected, straightforward cases.

SP9.1.4 Management of Small Bowel Obstruction: A Comparison to NASBO

Abstract Aim Prompt diagnosis and proactive decisions in management of small bowel obstruction (SBO) can reduce the associated morbidity, in-hospital stay and mortality. Following recommendations of National Audit of Small Bowel Obstruction (NASBO) and Bologna (2017), the “agreed pathway” of The Association of Surgeons of Great Britain and Ireland (ASGBI, 2018) sets clear guidelines to aid timely management of SBO. We aimed to audit our practice to these guidelines and compared outcomes to NASBO. Methods Data was collected retrospectively on patients admitted with SBO from July 2019 - December 2019 and presented as percentage, median or interquartile range (IQR). Results Median age of 76 included patients was 62.0 years, 53.9% were female. Aetiologies were; adhesions (59.2%), hernia (27.6%), malignancy (10.5%) and others (2.6%). Admission CTs were performed in 92.1% vs. 80.0% (NASBO), with a median time of 3.3 hours vs. 2.2 days (NASBO). Median time to surgery in those managed operatively (n = 35) was 10 hours vs. 1 day (NASBO), while in 72.0% vs. 21.0% (NASBO) of non-settling SBO, water soluble contrast study (WSCS) was performed in a median (IQR) time of 39.0 (20.0-45.4) hours. Adhesional SBO resolved in 85.7% of cases suitable for non-operative approach. Objective nutritional assessment was performed in 94.7% vs. 90.0% (NASBO). In-hospital stay, 30-day morbidity and mortality compared to NASBO were 5.0 vs. 10.7 days, 31.6% vs. 23.0% and 5.3% vs. 8.0% respectively. Conclusion ASGBI guidelines provide multi-faceted proactive approach in managing SBO; including early cross-sectional imaging, prompt WSCS use and timely nutritional interventions, promoting improved outcomes.

EP.FRI.614 An Atypical Case of Small Bowel Obstruction in the Virgin Abdomen: Case Presentation and Literature Review

Abstract Aims The management of post-operative adhesional small bowel obstruction (SBO) has shifted from the historical motto of “the sun should never rise and set on a complete SBO” to a non operative approach in selected patients. Despite this shift, the operative management of patients with SBO with a virgin abdomen is still encouraged. Methods We present an atypical case of SBO managed conservatively with resolution, without surgical intervention. A literature review is conducted and our case compared with the current literature. A treatment algorithm is presented. Results A 57 year old with a virgin abdomen presented with vomiting and abdominal pain. Computed tomography was consistent with mid to distal SBO proximal to the terminal ileum, in the context of a high riding caecum. He was managed conservatively. Symptoms resolved within 12 hours without gastrograffin. Gastrograffin was subsequently given to ensure contrast was present in the large bowel. At 6 month follow up he remains symptom free. Discussion Many advocate surgery is the cornerstone of the management of SBO in the virgin abdomen. There is little evidence to support this. Recent emerging evidence challenges this view. Ultimately the clinical evaluation of the patient is paramount in selecting which patients can be managed conservatively. A longer interval to operation may carry greater risk of ischaemia and bowel resection. Therefore careful patient selection and serial examination is vital and one should have a low threshold for early operative intervention in the patient which isn't settling. Follow up should be tailored to each patient.

EP.FRI.450 Gastrograffin use in Non-Adhesional Small bowel Obstruction

Abstract Aims Use of Gastrograffin (GG) radio-opaque contrast has been documented in the management of adhesional small bowel obstruction. It is not widely used in other causes of small bowel obstruction. The aim of this study was to assess the effectiveness of GG use in non-adhesive small bowel obstructions. Methods A retrospective review of patients who had GG administered following CT confirmed small bowel obstruction (SBO) over 2-year period was conducted. Demographics, cause of SBO and outcomes were recorded. The primary outcome was resolution of SBO with GG. Results 80 patients received GG for management of radiologically confirmed small bowel obstruction. The mean age was 62.7 years +/- 14.64 (SD) and M:F ratio was 1:1. The causes of small bowel obstruction included adhesions (n = 37, 46%), hernias (n = 17, 21%), progression of known cancer (n = 3, 4%). 18% (n = 15) had no clear cause of SBO on CT. In the adhesion group, GG resolved SBO in n = 27 (73%) of patients. In the hernia group 7 (41%) were incisional hernias and 7 (41%) were parastomal hernias. GG was given to both groups and the obstruction resolved in n = 6 (86%) and n = 4 (57%) of cases respectively. Conclusions This study shows the effective use of GG in hernia related SBO where there is no absolute indication for surgery. GG might be suitable for incisional and parastomal hernias as a bridge to resolving acute SBO allowing a delayed repair with complex techniques.

1494 An Audit on The Management of Adhesional Small Bowel Obstruction at St Helier Hospital

Abstract Aim To compare our current management of adhesional small bowel obstruction (ASBO) with the BMJ best practice treatment algorithm1 and National audit for small bowel obstruction 20172 guidelines and produce a flow chart to aid stasndardised : Method Data collected prospectively from the general surgical take list over a three-month. Results Thirty-five patients were diagnosed with ASBO. All patients were prescribed IV fluids. Thirty-four (97.1%) and 31 patients (88.6%) received analgesia and anti-emetics, respectively. Twenty-one patients (82.9%) had a NG tube inserted. Five patients (14.3%) underwent laparotomies within 37 hours from time of admission. Thirty patients (85.7%) underwent a trial of conservative management. Twenty-four patients (80%) received water-soluble contrast, of whom 13 (59.1%) were managed successfully. Eight patients (36.3%) failed to resolve and underwent emergency laparotomy within 70 hours from admission. One patient (2.9%) failed conservative management and was palliated. Conclusions Our results are in line with national standards. Our first line management for ASBO (analgesia, anti-emetics and NG insertion) could be instituted more promptly. Failure of NG insertion is multifactorial, an improved insertion rate may have further positive impact on conservative management outcome. A step-by-step sequential flow chart could introduce on induction at the beginning of general surgical rotation could help to re-iterate this management.

The impact of laparoscopy on emergency surgery for adhesional small bowel obstruction: prospective single centre cohort study.

Laparoscopic adhesiolysis is increasingly being used to treat adhesional small bowel obstruction (ASBO) as it has been associated with reduced postoperative length of stay (LOS) and faster recovery. However, concerns regarding limited working space, iatrogenic bowel injury and failure to relieve the obstruction have limited its uptake. This study reports our centre's experience of adopting laparoscopy as the standard operative approach. A single-centre prospective cohort study was performed incorporating local data from the National Emergency Laparotomy Audit Database; January 2015 to December 2019. All patients undergoing surgery for ASBO were included. Patient demographic, operative and inhospital outcomes data were compared between different surgical approaches. Linear regression analysis was performed for LOS. A total of 299 cases were identified. Overall, 76.3% of cases were started laparoscopically and 52.2% were completed successfully. Patients treated laparoscopically had lower Portsmouth - Physiological and Operative Severity Score for the enuMeration of Mortality and morbidity (P-POSSUM) predicted mortality (median 2.1 (interquartile range (IQR) 1.3-5.0) vs 5.7 (IQR 2.0-12.4), p=<0.001) and shorter postoperative LOS compared with open (median 4.2 days (IQR 2.5-8.2) vs 11.3 days (IQR 7.3-16.6), p=0.000). Inhospital mortality was lower in the laparoscopic group (2 vs 7 deaths, p=<0.001). In regression analysis, laparoscopic surgery was found to have the strongest association with postoperative LOS (β -8.51 (-13.87 to -3.16) p=0.002) compared with open surgery. Laparoscopy is a safe and feasible approach for adhesiolysis in the majority of patients with ASBO. It is associated with reduced LOS with no impact on complications or mortality.

Role of Gastrografin in Patients With Small Bowel Obstruction.

IntroductionGastrografin (GGF) is a radiopaque contrast medium commonly used for diagnostic examination of the gastrointestinal (GI) tract. Available evidence suggests it has therapeutic and predictive value in the management of adhesional small bowel obstruction (ASBO). Thus, we investigated the use of GGF amongst patients who had a small bowel obstruction and audited the practice in University Hospital, Ayr.MethodsInitial retrospective data of patients who had gastrografin for small bowel obstruction were extracted from April 2015 to August 2019 and analysed. After our local presentation and on implementing a GGF protocol, we prospectively collected data from February to June 2020 to close our audit.ResultsGGF showed a comparable therapeutic effect on ASBO in both audit cycles (72.2%-66.7%). Approximately 50% of unresolved cases were operated within 24 hours of GGF administration in both cycles. GGF consistently demonstrated a therapeutic benefit in refractory faecal impaction (100% in both cycles) and postoperative ileus (≥ 80%). Early use of computed tomography (CT) (less than 24 hrs) did not confer any added advantage (82.5% v 61.5%), however, it helped in making an appropriate diagnosis and the subsequent early gastrografin usage (78.3% v 92.3%) in ASBO.ConclusionGGF serves a very good therapeutic purpose in resolving ASBO, refractory constipation, and in rare non-resolving cases of postoperative ileus. Early CT diagnosis of ASBO is advocated before the administration of gastrografin. Unsuccessful resolution after 24 hrs of GGF is an indication for operative intervention.

Acute small bowel obstruction: one-year retrospective study of admissions to inner city Royal Perth Hospital.

Analyse admissions to Royal Perth Hospital (RPH) with acute small bowel obstruction (SBO), and identify trends between outcomes and management. Retrospective, single-centre review of patients admitted to RPH with acute SBO, between May 2017 and May 2018. A total of 251 admissions met inclusion criteria. Increasing age correlated with increasing total length of stay (LOS) (r = 0.134, P = 0.033) and post-operative LOS (r = 0.349, P < 0.0001). Increasing age led to poorer outcomes (P < 0.0001). Diagnoses were most commonly adhesions (167/251 = 66.5%), hernias (47/251 = 18.7%) and inflammatory bowel diseases (11/251 = 4.4%). Operation rate for adhesional SBO was 24.6% (41/167) and non-adhesional SBO 54.8% (46/84). Median total LOS for operative versus conservative management was 9 days (interquartile range (IQR) 8) versus 3 days (IQR 3) (P < 0.0001). Median time to surgery was 1 day (IQR 2). Increased time from admission to theatre led to increasing post-operative LOS (r = 0.398, P = 0.0013). Median post-operative LOS for bowel resection versus no resection was 9 days (IQR 4.5) versus 6 days (IQR 4) (P = 0.0128). Of 101, 81 (80.2%) adhesional SBO resolved non-operatively after receiving Gastrografin, compared to 45 of 66 (68.2%) of those who did not (P = 0.07). It did not significantly alter total or post-operative LOS (P = 0.65 and P = 0.96), patient outcome (P = 0.26), or need for bowel resection (P = 0.63). Operative management, bowel resection, older age and increasing time from admission to surgery increase LOS. Trial of Gastrografin in non-operative management of adhesion type small bowel obstructions does not significantly affect outcomes but tends to reduce operative rates.

A Case Report of Adhesional Small Bowel Obstruction Caused by Extraintestinal Anisakiasis

Small bowel obstruction (SBO) is a common diagnosis made in the emergency department (ED). We present a case with an unusual underlying cause of SBO: extraintestinal infection with an Anisakis roundworm. A healthy young woman with no prior abdominal surgery presented with epigastric abdominal pain, nausea, and anorexia 1day after eating a raw oyster. Laboratory studies were significant for 14% eosinophilia. Initial abdominal computed tomography (CT) showed small bowel inflammation and small-volume ascites. After discharge home, she returned on day 14 of illness with a closed-loop SBO, to which she was predisposed by an adhesion formed in association with an eosinophilic abscess containing an Anisakis roundworm. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Anisakiasis is an uncommon cause of common symptoms with which patients may present to EDs. The diagnosis should be considered in patients presenting with abdominal pain and recent ingestion of raw seafood, with suspicion raised further by the presence of focal gastric or small bowel inflammation and ascites on abdominal CT. Extraintestinal anisakiasis can cause inflammation leading to intraabdominal adhesions, a sequela of which is small bowel obstruction. If suspicion for gastric or intestinal anisakiasis is high, treatment with endoscopic removal or albendazole may be initiated.

The effects of recreational ketamine cystitis on urinary tract reconstruction - a surgical challenge.

To identify the rate of postoperative complications in patients who require surgical reconstruction for ketamine-induced urinary tract dysfunction and to identify any predictors for poor postoperative outcome with subsequent management strategies. A retrospective review of data collected between 2007 and 2017 of all patients with ketamine-induced urinary tract disease was performed. Evaluation included computed tomography urogram, cystoscopy, and biopsy. Indications and outcomes for surgical intervention were assessed. In all, 44 patients were identified of which 68% were male. The mean (range) age at presentation was 31 (23-55) years. All bladder biopsies confirmed an eosinophilic inflammatory infiltrate. A significant proportion of patients (81.8%) were found to have reduced cystoscopic bladder capacity of <300 mL (mean 196, range 25-550 mL). In all, 29 patients were treated conservatively with a view to symptom resolution. Two patients underwent dilatation for urethral strictures. Four patients underwent repeated intra-detrusor onabotulinum toxin injection with minimal subjective symptom relief. Two of these patients proceeded to have major reconstruction. Indications for urinary tract reconstruction included intractable symptoms, high-pressure compliance loss with renal compromise and ureteric obstruction. Patients were advised to abstain from ketamine use for a minimum of 6 months prior to consideration of surgical intervention. A total of 14 patients underwent major reconstruction. Surgical intervention included ileal conduit urinary diversion, augmentation cystoplasty with or without Mitrofanoff channels, ureteric re-implantation, and cystectomy with neobladders. Complications included anastomotic leaks, ureteric strictures, adhesional small bowel obstruction, renal failure, and sepsis. Overall, complications occurred in 10/14 patients. In a tertiary high-volume reconstructive unit, ketamine patients were at high risk of significant perioperative complications. There did not appear to be any other common factor apart from their use of ketamine, and the significant inflammatory change associated with this. We recommend meticulous preoperative evaluation and multidisciplinary consultation for all patients to determine optimal treatment strategies.