Diagnosis Of Small Bowel Obstruction Research Articles

Optimal bowel diameter thresholds for diagnosing small bowel obstruction and surgical intervention with point-of-care ultrasound

ObjectivesA bowel diameter threshold of ≥2.5 cm, originally derived from the research using computed tomography, is frequently used for diagnosing small bowel obstruction (SBO) with point-of-care ultrasound (POCUS). We sought to determine the optimal bowel diameter threshold for diagnosing SBO using POCUS and its accuracy in predicting surgical intervention. MethodsWe conducted a secondary analysis using individual patient-level data from a previous systematic review on POCUS for SBO diagnosis across five academic EDs. Patient data were collected, including imaging results, surgical findings, and final diagnosis. The measured diameter of the small bowel using POCUS was recorded. ROC area under the receiver operating characteristic curves (AUC) were constructed to determine the optimal threshold for bowel diameter in predicting SBO diagnosis and surgical intervention. Subgroup analyses were performed based on sex and age. ResultsA total of 403 patients had individual patient-level data available, with 367 patients included in the final analysis. The most accurate bowel diameter overall for predicting SBO was 2.75 cm (AUC = 0.76, 95% CI 0.71–0.81). A bowel diameter of ≤1.7 cm had 100% sensitivity with no miss rate, while a bowel diameter of ≥4 cm had 90.7% specificity in confirming SBO. Patients under 65 had an optimal threshold of 2.75 cm versus 2.95 cm in patients over 65. Females had an optimal threshold of 2.75 cm, while males had a value of 2.95 cm. There was no significant correlation between bowel diameter thresholds and surgical intervention. ConclusionA bowel diameter threshold of 2.75 cm on POCUS is more discriminative diagnostic accuracy for diagnosing SBO. Patients' age and sex may impact diagnostic accuracy, suggesting that tailored approaches may be needed.

Indications for Readmission for Small Bowel Obstruction: A Comparison of Medical vs Surgical Service Admission.

Small bowel obstruction (SBO) impacts the health care system and patient quality of life. Previously, we evaluated differences between medical and surgical admissions in the management of SBO. This study investigates indications for readmission based on original admission to medical (MS) or surgical services (SS). A retrospective chart review was performed for 799 patients aged 18 to 89 admitted between 2012 and 2019 with a diagnosis of SBO. Patient characteristics examined included length of stay (LOS), prior abdominal operations, prior SBO, use of small bowel follow through imaging, operative intervention, mortality, and 30-day readmission. There was no difference in readmission rates in patients originally admitted to MS or SS (13.2% vs 12.7%, P = .86). Patients admitted to SS were more likely to be readmitted for recurrent SBO (39% vs 8.6%, P = .006). Patients admitted to MS were more likely to be readmitted for other reasons (73.9% v. 40.2%, P = .004). In the MS cohort, 30.4% (7 patients) had surgery during their initial admission for SBO, and none of those patients were readmitted for recurrent SBO (rSBO). In the SS cohort, 23% had surgery during their initial admission and 31.6% were readmitted for rSBO (P = .002). Patients admitted to SS were more likely to be readmitted for rSBO and to require surgery. Patients admitted to MS were more likely to be readmitted for other reasons. None of the MS patients who had surgery were readmitted for SBO. 31.6% of SS patients who had surgery were readmitted for SBO.

Integrating Pre-test Probability and Point-of-Care Ultrasound (POCUS) in the Emergency Department (ED) Diagnosis of Small Bowel Obstruction (SBO).

Introduction A computed tomography (CT) scan and point-of-care ultrasound (POCUS) are commonly employed for diagnosing small bowel obstructions (SBOs). Prior studies demonstrated that POCUS has 90-95% sensitivity and specificity compared with CT scanning, which is the gold standard. Unlike other imaging modalities (in which the ordering and performing clinician are not the same), POCUS-performing/interpreting sonologists must recognize the risk of confirmation bias in the POCUS application. Per Bayesian analysis, the likelihood of a diagnosis being true following a diagnostic test is based on the ordering clinician's pre-test probability and the test characteristics (sensitivity and specificity, from which positive and negative likelihood ratios can be calculated). Consequently, establishing pre-test probability is important in informing downstream diagnostic or therapeutic interventions, as pre-test probability influences post-test odds. Little research has been done on the role of POCUS sonologist's pre-test probability and actual POCUS results regarding SBO. This study assessed the role of POCUS, integrating pre-test probability and POCUS results to determine post-test odds. Methods One hundred six patients were recruited on a convenience basis and underwent POCUS and CT between April 2017 and December 2022. All sonographers were credentialed in POCUS. POCUS sonologists' pre-test probabilities and POCUS and CT results were captured, which were compared. Sensitivity, specificity, LR+, and LR- were calculated, and correlations were made between pre-test probability and POCUS and CT results. Results POCUS exhibited a sensitivity of 92% and specificity of 90%, with a corresponding positive likelihood ratio (LR+) of 9.3 and a negative likelihood ratio (LR-) of 0.09 for diagnosing SBO. Among patients with a high pre-test probability of SBO, a negative ultrasound yielded post-test odds of 0.4%, whereas a positive POCUS yielded post-test odds of 39.6%. Among patients with a low pre-test probability, a negative POCUS resulted in post-test odds of 0%, while a positive POCUS led to post-test odds of 2.1%, yielding a number needed to scan (NNS) of ~50 to identify a patient with an SBO on CT. Conclusion This study confirmed POCUS's sensitivity and specificity of ~90-95% and a corresponding LR+ of 9.2 and LR- of 0.9. Pre-test probability substantially affected post-test odds. Patients with a high pre-test probability and a positive POCUS had post-test odds of 39.6 and should have a confirmatory CT, while those with a negative POCUS have very low post-test odds and very likely will not benefit from CT. Patients with low pre-test probability and a positive POCUS have post-test odds of 2.1%, similar to the Wells Score and HEART score; such patients may not benefit from a CT, though clinicians should use their judgment/discretion. Patients with a low pre-test probability and a negative POCUS have post-test odds of 0% and should not have a CT. Among low pre-test probability patients, the NNS was ~50 to identify patients with an SBO on CT.

Diagnostic Performance of Ultrasonography for Identification of Small Bowel Obstruction; a Systematic Review and Meta-analysis.

Small bowel obstruction (SBO) is known as a common cause of acute abdominal complaints in the emergency department (ED). The modality of choice for the diagnosis of SBO has not yet been established. This systematic review and meta-analysis aimed to investigate the accuracy of ultrasonography for the diagnosis of SBO. Systematic search was performed on five electronic databases including Medline, Scopus, Web of Sciences, Embase, and Cochrane Library, and the retrieval period was from the inception of each database to November 2023. The quality of the included studies were investigated using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). The pooled values of diagnostic characteristics for ultrasonography were estimated using meta-Disc and Stata statistical software. Twenty-one studies with a total of 1977 patients were included in the meta-analysis. The pooled estimate for sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the summary ROC curve of ultrasonography for diagnosing SBO were 0.93 (95% CI: 0.91-0.95), 0.8 (95% CI: 0.77-0.83), 5.69 (95% CI: 3.64-8.89), 0.1 (95% CI: 0.07-0.16), 83.51 (95% CI: 18.12-182.91) and 0.96, respectively. The findings of this meta-analysis showed that the utilization of ultrasonography holds promise as a diagnostic imaging for SBO with high accuracy. However, additional worldwide studies are essential to get more evidence on the value of ultrasonography for the diagnosis of SBO.

A Case of Bowel Obstruction Due to A Rare Supra-Vesical Hernia

Intestinal obstruction is one of the common causes’ emergency department visits, the prompt management of which is complicated by wide array of causes. Supra-vesical hernia has been reported to be a rare surgical cause of obstruction. Early diagnosis is often difficult and therefore can it has high chances of acute & emergent presentation. Prompt recognition of symptoms and evaluation are important to prevent poor prognosis. We are presenting a case of 62-year-old, medical free, male patient presenting to emergency department with clinical picture of abdominal obstruction. Based on the clinical examination and abdominal radiography, a provisional diagnosis of small bowel obstruction was made. CT scan confirmed the diagnosis with further specifying the extent of the hernial sac reaching up to the urinary bladder. The patient was managed successfully through exploratory laparotomy with no injury to the urinary bladder.

Case Report: Laparoscopy-assisted resection for intra-abdominal gossypiboma masquerading as a jejunal tumor (with video)

IntroductionIntra-abdominal gossypiboma, a cotton-based retained foreign body after an abdominal surgery, is associated with various clinical manifestations and complications. Its infrequent occurrence and unpredictability make its early diagnosis particularly challenging. We herein present an atypical case of intra-abdominal gossypiboma mistaken for a jejunal tumor.Case presentationA 33-year-old female presented to the emergency room with an acute episode of progressive abdominal pain and distention, nausea, and vomiting for 20 hours. She had undergone an urgent cesarean section due to fetal tachycardia seven years prior. The initial diagnosis of small bowel obstruction (SBO) due to a jejunal tumor was established by computed tomography. Subsequent to successful medical management of the SBO, a laparoscopy-assisted resection of the mass and the adherent jejunal segment was conducted, culminating in a primary side-to-side jejunojejunostomy. Examination of the excised tissue revealed an approximately spherical fibrous mass, 6 × 6 × 5 cm in dimension, embedded in the jejunal wall, housing a 20 × 20-cm gauze. Postoperative recovery and routine follow-up ensued without complications.ConclusionIn light of this case, the need for clinicians to maintain an elevated awareness and suspicion of gossypiboma should be accentuated when evaluating an intra-abdominal mass, especially in patients with a prior history of high-risk laparotomy. Laparoscopic surgery stands out as a technically proficient and minimally invasive strategy for diagnosing and treating intra-abdominal gossypiboma. Besides, it is imperative to emphasize the importance of meticulous surgical procedures and postoperative protocols to prevent such oversights, reaffirming the need for consistent intraoperative counts and checks of surgical items.

The Clinical Frailty Scale (CFS) as an Independent Prognostic Factor for Patients ≥80 Years with Small Bowel Obstruction (SBO)

BackgroundSBO is a potentially life-threatening condition that often affects older patients. Frailty, more than age, is expected to play a crucial role in predicting SBO prognosis in this population. This study aims to define the influence of Clinical Frailty Scale (CFS) on mortality and major complications in patients ≥80 years with diagnosis of SBO at the emergency department (ED). MethodsAll patients aged ≥80 years admitted to our ED for SBO from January 2015 to September 2020 were enrolled. Frailty was assessed through the CFS, and then analyzed both as a continuous and a dichotomous variable. The endpoints were in-hospital mortality and major complications. ResultsA total of 424 patients were enrolled. Higher mortality (20.8% vs 8.6%, p<0.001), longer hospital stay (9 [range 5–14] days vs 7 [range 4–12] days, p=0.014), and higher rate of major complications (29.9% vs 17.9%, p=0.004) were associated with CFS ≥7. CFS score and bloodstream infection were the only independent prognostic factors for mortality (OR 1.72 [CI: 1.29–2.29], p<0.001; OR 4.69 [CI: 1.74–12.6], p=0.002, respectively). Furthermore, CFS score, male sex and surgery were predictive factors for major complications (OR 1.41 [CI: 1.13–1.75], p=0.002; OR 1.67 [CI: 1.03–2.71], p=0.038); OR 1.91 [CI: 1.17–3.12], p=0.01; respectively). At multivariate analysis, for every 1-point increase in CFS score, the odds of mortality and the odds of major complications increased 1.72-fold and 1.41-fold, respectively. ConclusionThe increase in CFS is directly associated with an increased risk of mortality and major complications. The presence of severe frailty could effectively predict an increased risk of in-hospital death regardless of the treatment administered. The employment of CFS in elderly patients could help the identification of the need for closer monitoring and proper goals of care.

ThTP5.12 Assessment of malnutrition and nutritional interventions in patients presenting with acute small bowel obstruction – are we ‘getting it right first time’?

Abstract Aims High levels of morbidity and mortality are associated with small bowel obstruction (SBO), a common general surgical emergency. Assessment of malnutrition and introduction of early nutritional interventions are of paramount importance in the management algorithm of these patients. We audited our practice of managing acute small bowel obstruction at a busy district general hospital comparing our practice against National Audit of Small Bowel Obstruction (NASBO) recommendations. Methods Data were gathered for all patients presenting with bowel obstruction to our Trust between 01/08/2022 and 30/11/2022. In depth review of patient case records was undertaken using electronic patient record systems (e-Track and Evolve). Results 195 patients were admitted with acute bowel obstruction. 68 patients (35%) had acute SBO (M: F; 34:34). 58 (85%) had no documentation of duration for which they had been ‘nil by mouth’ (NBM) prior to hospitalisation. Malnutrition universal screening tool score (MUST score) was completed in 29 (43%) patients. 59% of patients had an emergency computed tomography (CT) which confirmed diagnosis of SBO. 60% of patients were managed non-operatively. On an average, patients were kept ‘NBM’ for two days (range; 1-16 days). Average waiting time for peripherally inserted central catheter (PICC) was 9.6 days. Conclusions Evaluating our practice of managing patients with acute SBO has highlighted multiple areas for improvement to ‘get it right first time’. We have included stakeholders; nursing staff, dieticians, surgeons, junior doctors and vascular access team to implement action plan to optimise management in this cohort of patients in line with NASBO guidelines.

Optimal Time to Surgery for Small Bowel Obstruction: A Risk Adjusted Analysis Utilizing the Nationwide Inpatient Sample.

The management of a small bowel obstruction (SBO) remains a challenge for general surgeons. The majority of SBOs can be treated conservatively; however, when surgery is required, the timing of operative intervention remains uncertain. Utilizing a large national database, we sought to evaluate the optimal timeframe for surgery following hospital admission with a diagnosis of SBO. This was a retrospective review utilizing the Nationwide Inpatient Sample (2006-2015). Outcomes following surgery for SBO were identified using ICD-9-CM coding. Two comorbidity indices were utilized to determine severity of illness. Patients were stratified into four groups based on time in days from admission to surgery. Propensity score models were created to predict the number of days until surgery following admission. Multivariate regression analysis was performed to determine risk adjusted postoperative outcomes. We identified 92807 cases of non-elective surgery for SBO. The overall mortality rate was 4.7%. Surgery on days 3-5 was associated with the lowest rate of mortality. A longer preoperative length of stay (LOS) (3-5days) was associated with a significantly greater number of wound (OR = 1.24) and procedural (OR = 1.17) complications compared to day 0. However, delayed surgical intervention (≥6days) was associated with decreased cardiac (OR = .69) and pulmonary complications (OR = .58). After adjustment, a preoperative LOS of 3-5days was associated with a decreased risk of mortality. In addition, increasing preoperative LOS was associated with decreased cardiopulmonary complications. However, an increased risk of procedural and wound complications during this time period suggest surgery may be more technically challenging.

Multi-center analysis of point-of-care ultrasound for small bowel obstruction: A systematic review and individual patient-level meta-analysis

ObjectiveThe study aimed to assess the diagnostic accuracy of point-of-care ultrasound (POCUS) in identifying small bowel obstruction (SBO) and to investigate the impact of clinician experience level and body mass index (BMI) on POCUS performance for diagnosing SBO in the Emergency Department. MethodsWe systematically searched PubMed and Cochrane databases from January 2011–2022. We performed a meta-analysis using individual patient-level data from prospective diagnostic accuracy studies from which we obtained data from the corresponding authors. Overall test characteristics and subgroup analysis across clinician experience levels and a range of BMI were calculated. The primary outcome was SBO as the final diagnosis during hospitalization. ResultsWe included Individual patient data from 433 patients from 5 prospective studies. Overall, 33% of patients had a final diagnosis of SBO. POCUS had 83.0% (95%CI 71.7%–90.4%) sensitivity and 93.0% (95%CI 55.3%–99.3%) specificity; LR+ was 11.9 (95%CI 1.2–114.9) and LR- was 0.2 (95%CI 0.1–0.3). Residents had exhibited a sensitivity of 73.0% (95%CI 56.6%–84.9%) and specificity of 88.2% (95%CI 58.8%–97.5%), whereas attendings had demonstrated a sensitivity of 87.7% (95%CI 71.1%–95.4%) and specificity of 91.4% (95%CI 57.4%–98.8%). Among those patients with BMI<30 kg/m2, POCUS showed a sensitivity of 88.6% (95%CI 79.5%–94.7%) and a specificity of 84.0% (95%CI 75.3%–90.6%), while patients with BMI ≥ 30 kg/m2 exhibited a sensitivity of 72.0% (95%CI 50.6%–87.9%) and specificity of 89.5% (95%CI 75.2%–97.1%). ConclusionsPOCUS correctly identified those patients with SBO with high sensitivity and specificity. Diagnostic accuracy was slightly reduced when performed by resident physicians and among patients with a BMI ≥ 30 kg/m2.Registration: PROSPERO registration number: CRD42022303598.

Implementation of a Gastrografin Order Set for Small Bowel Obstruction Across a Health System: A Cohort Study.

The use of Gastrografin (GG) in the management of adhesive small bowel obstruction (SBO) has been shown to decrease the length of stay and operative intervention. This retrospective cohort study examined patients with an SBO diagnosis prior to implementation (PRE, January 2017-January 2019) and following implementation (POST, January 2019-May 2021) of a GG challenge order set made available across 9 hospitals within a health care system. Primary outcomes were utilization of the order set across facilities and over time. Secondary outcomes included time to surgery for operative patients, rate of surgery, nonoperative length of stay, and 30-day readmission. Standard descriptive, univariate, and multivariable regression analyses were performed. PRE cohort had 1746 patients and POST had 1889. The utilization of GG increased from 14% to 49.5% following implementation. Significant variability existed within the hospital system with utilization at each individual hospital from 11.5% to 60%. There was an increase in surgical intervention (13.9% vs 16.4%, P = .04) and decrease in nonoperative LOS (65.6 vs 59.9hours, P < .001) following implementation. For POST patients, multivariable linear regression showed significant reduction in nonoperative length of stay (-23.1hours, P < .001) but no significant difference in time to surgery (-19.6hours, P = .08). The availability of a standardized order set for SBO can result in increased Gastrografin administration across hospital settings. The implementation of a Gastrografin order set was associated with decreased length of stay in nonoperative patients.

Survey of Diagnostic and Management Practices in Small Bowel Obstruction: Individual and Generational Variation Despite Practice Guidelines.

Background: Small bowel obstruction (SBO) is a common disorder managed by surgeons. Despite extensive publications and management guidelines, there is no universally accepted approach to its diagnosis and management. We conducted a survey of acute care surgeons to elucidate their SBO practice patterns.Methods: A self-report survey of SBO diagnosis and management practices was designed and distributed by email to AAST surgeons who cared for adult SBO patients. Responses were analyzed with descriptive statistics and Chi-square test of independence at α = .05.Results: There were 201 useable surveys: 53% ≥ 50years, 77% male, 77% at level I trauma centers. Only 35.8% reported formal hospital SBO management guidelines. Computed tomography (CT) scan was the only diagnostic exam listed as "essential" by the majority of respondents (82.6%). Following NG decompression, 153 (76.1%) would "always/frequently" administer a water-soluble contrast challenge (GC). There were notable age differences in approach. Compared to those ≥50years, younger surgeons were less likely to deem plain abdominal films as "essential" (16.0% vs 40.2%; P < .01) but more likely to require CT scan (88.3% vs 77.6%; P = .045) for diagnosis and to "always/frequently" administer GC (84.0% vs 69.2%; P < .01). Younger surgeons used laparoscopy "frequently" more often than older surgeons (34.0% vs 21.5%, P = .05).Discussion: There is significant variation in diagnosis and management of SBO among respondents in this convenience sample, despite existing PMGs. Novel age differences in responses were observed, which prompts further evaluation. Additional research is needed to determine whether variation in practice patterns is widespread and affects outcomes.

Management and short-term outcomes of patients with small bowel obstruction in Denmark: a multicentre prospective cohort study.

The optimal management of small bowel obstruction (SBO) remains a matter of debate and treatment varies internationally. In Denmark, a more surgically aggressive strategy has traditionally been used, but to what extent patient outcomes differ from international reports is unknown. This study aimed to describe the current management and outcomes of patients admitted with SBO in Denmark. This was a prospective cohort study conducted at six acute hospitals in Denmark over a 4-month period. Patients aged ≥ 18years with a clinical or radiological diagnosis of SBO were eligible. Primary outcomes were 30day morbidity and mortality rates. 316 patients were included during the study period. The median age was 72years and 56% were female. Diagnosis was made by computed tomography (CT) in 313 patients (99.1%), with the remaining three diagnosed clinically. Non-operative management was the initial strategy in 152 patients (48.1%) and successful in 119 (78.3%). Urgent surgery was performed in the remaining 164 (51.9%), with a laparoscopic approach used in 84 patients (51.2%). The entire cohort had a 30day mortality rate of 7.3% and a 30day morbidity rate of 17.1%. The management of SBO in Denmark differs markedly to previous international reports, with an almost ubiquitous use of CT for diagnosis and a high proportion of patients undergoing urgent surgery. Despite higher rates of surgery, patient outcomes are broadly similar to reports of more conservative strategies, perhaps due to a reduction in delayed operations. Trial registration number: NCT04750811.Trial registration date: 11/02/2021.

Elastotic Mass-Forming Lesion of the Omentum; A New Pathological Entity

Abstract Introduction/Objective Elastotic lesions are rare benign mass-forming entity. Although, few reports of mucosal and submucosal elastotic lesions have been previously described, localization of these lesions in the omentum is not previously described in the literature. Methods/Case Report We report a case of 60-year-old man with medical history of obesity, hypertension, diabetes mellitus, and a remote abdominal surgery in 1980s who presented to the emergency room complaining of abrupt severe constant epigastric pain that started few hours before. The pain was not relieved by antiacid or analgesic medications. CT of the abdomen showed multiple distended fluid-filled loops of small bowel in mid abdomen with infiltrative changes of mesentery. A diagnosis of small bowel obstruction was made, and patient proceed to have an exploratory laparotomy. During the procedure, extensive adhesions between small bowel and omentum and small bowel obstruction due to a phytobezoar were noted for which he underwent lysis of adhesion, excision of thickened omentum, and enterotomy for removal of significant food bezoar. Grossly, the omentum has multiple chalky tan-gray masses ranging between 1.2 and 1.0 cm in greatest dimension surrounded by indurated fatty tissue. Microscopically, multiple hypocellular foci are seen that are composed almost entirely of truncated elastic fibers, with sparse delicate bands of collagen and scattered prominent thick-walled vessels. Elastic stain highlights these elastic fibers while trichrome stains the elastic fibers pale gray in contrast to the bright blue color of the collagen fibers. Mucicarmine, and Congo red are negative. Patient tolerated the procedure well however, postoperatively he had local wound infection leading to prolonged skin dehiscence. Results (if a Case Study enter NA) NA. Conclusion Elastotic mass-forming lesions in the omentum is a new entity that has not been described before in this location that can clinically manifest with signs and symptoms of bowel obstruction. We suggested the name of elastomatosis omentum.

Survey of Diagnostic and Management Practices in Small Bowel Obstruction: Individual and Generational Variation Despite Practice Guidelines

Introduction: Small bowel obstruction (SBO) is among the most common disorders managed by acute care surgeons. Despite extensive publications and an Eastern Association for the Surgery of Trauma (EAST) practice management guideline (PMG), there is no universally accepted approach to the diagnosis and management of SBO. We conducted a survey of trauma surgeons to elucidate their current SBO practice patterns. Methods: A self-report survey of SBO diagnosis and management practices in adults was designed and distributed by email to American Association for the Surgery of Trauma member surgeons who directly cared for SBO patients. Responses were analyzed with descriptive statistics and Chi-Square test of independence at α=.05. Results: There were 201 useable surveys: 53% ≥50 years, 77% male, 77% at Level I trauma centers. Formal hospital SBO management guidelines were reported by only 35.8%. CT scan was the only diagnostic exam listed as “essential” by most respondents (82.6%). After NG decompression, 153 (80.1%) would always/frequently administer gastrografin challenge (GC). There were notable age differences in approach. Surgeons 30-49 years were less likely to deem plain abdominal films as ‘essential’ (16.0% vs 40.2%; p < .001), but more likely to require CT scan (88.3% vs 77.6%; p = .045) for diagnosis, and to always/frequently administer GC (84.0% vs 69.2%; p < .01) compared with those ≥50 years. Conclusion: Among respondents in this convenience sample, there is significant variation in the diagnosis and management of SBO despite a specific EAST PMG. Novel age differences in responses were observed and prompt further evaluation. Additional research is needed to determine whether variation in practice patterns is widespread and affects patient outcomes.

SP3.2.1 Management and outcomes of patients with small bowel obstruction in Denmark – a multicentre prospective cohort study

Abstract Aims The optimal management of small bowel obstruction (SBO) remains a matter of debate and treatment varies internationally. In Denmark, the traditional approach to patients with SBO is less conservative than that of the UK, but to what extent patient outcomes differ is unknown. This study aimed to describe the current management and outcomes of patients admitted with SBO in Denmark. Methods This was a prospective cohort study conducted at 6 acute hospitals in Denmark over a 4-month period. Patients aged &amp;gt; 18 years with a clinical or radiological diagnosis of SBO were eligible. Primary outcomes were 30-day mortality and major complication rates. Results 316 patients were included during the study period. The median age was 72 years and 56.0% were female. Diagnosis was made by computed tomography (CT) in 314 patients (99.1%), with the remaining 2 diagnosed clinically. Non-operative management was the initial strategy in 152 patients (48.1%) and successful in 120 (78.9%). Immediate surgery was performed in the remaining 164 (51.9%), with a laparoscopic approach used in 84 patients (51.2%). The 30-day mortality rate was 7.3% with major complications occurring in 61 patients (19.3%). Conclusions The management of SBO in Denmark differs significantly to that of the UK, with more liberal use of CT, a higher proportion of patients undergoing immediate surgery and a higher success rate of non-operative management. Despite these differences, patient outcomes are broadly similar. Adoption of the best components of both strategies may improve patient outcomes in both nations.

Pre-hospital caloric deficits in surgical patients.

The timing, route, and amount of nutrition for surgical patients with substantial caloric deficits remain active areas of study. Current guidelines are based on in-hospital days NPO after admission to the hospital. This historic process neglects the multiple days of caloric deficit patients experience prior to hospital admission. To determine the impact of pre-hospital caloric deficit (PHCD) for surgical patients on their outcomes. 313 patients admitted with a diagnosis of small bowel obstruction, pancreatitis, or diverticulitis were analyzed for their PHCD's. PHCD's were estimated using patient-reported days with significant emesis, and absent oral intake. Patients with PHCD's were compared to patients with no PHCD for length of stay, status on discharge, disposition, and 30-day readmission rate. There were 313 patients and 42% of the patients were male. The median age was 65 years. Median number of days sick prior to hospital admission was 1 (IQR: 1 to 2). Median PHCD was 1882 kcal (IQR: 1355 to 3650). Median number of days NPO while in-hospital was 3 (IQR: 2 to 5). Median in-hospital caloric deficit was 4268 kcal (IQR: 2825 to 6610). No significant association was observed between discharge disposition, complication rate, ambulatory status, 30-day readmission rate and PHCD. In-hospital caloric deficit was associated with complications after surgery (p < 0.0001). Small PHCD's in patients with SBO's, pancreatitis, or diverticulitis do not negatively affect their outcomes. Further research of patients with large PHCD's is needed to best treat surgical patients at risk for malnutrition.

Ileocecal valve-sparing surgery for duplication cysts in the terminal ileum: two case reports and literature review

BackgroundDuplication cysts close to the ileocecal valve are usually treated with ileocecal resection. However, loss of the ileocecal valve will lead to problems, especially in infants. Mucosectomy of the cyst would be a better alternative that preserves the ileocecal valve. We report two cases of duplication cyst in the terminal ileum successfully treated with mucosectomy.Case presentationCase 1. A 3-month-old boy with bilious emesis and abdominal distention was referred to our hospital with a diagnosis of small bowel obstruction caused by an abdominal cyst. Computed tomography revealed a cystic mass compressing the terminal ileum and causing mechanical small bowel obstruction. His general condition deteriorated quickly; emergency laparotomy was performed. Although the small intestines were dilated and partially twisted, there was no necrosis. Following intestinal decompression, a cystic mass adjacent to the terminal ileum was confirmed on the mesenteric side. Cyst mucosectomy was performed to preserve the ileocecal valve. Case 2. A 5-month-old boy with sudden onset of hematochezia was referred to our hospital with a diagnosis of intussusception. Following unsuccessful contrast enemas, emergency surgery was performed. A cystic mass adjacent to the terminal ileum was confirmed; there was no intussusception. Cyst mucosectomy was performed. Both patients had an uneventful postoperative course.ConclusionsCyst mucosectomy, which preserves the ileocecal valve, is safe and effective for treating duplication cysts in the terminal ileum.

Risk of Reopening of the Mesenteric Defects After Routine Closure in Laparoscopic Roux-en-Y Gastric Bypass: a Single-Centre Experience.

Small bowel obstruction (SBO) due to internal hernias (IH) is a well-recognised complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). Routine closure of the mesenteric defects (MDs) is recommended to reduce the risk of IH and subsequent SBO. However, data about the rates of reopening of the MDs after LRYGB is scarce. The main aim of this study was to evaluate the risk of reopening of the MDs after routine closure during LRYGB. The secondary objective was to determine any risk factors associated with the reopening of the MDs. Data of all patients who underwent reoperations after LRYGB with closure of both MDs between January 2010 and December 2018 were retrospectively reviewed. A total of 162 patients were included. The median time between LRYGB and reoperation was 17months. At the time of reoperation, both MDs were closed in 83 patients (51.2%); thus, 79 patients (48.8%) presented at least one open MD. The group of patients with preoperative diagnosis of SBO or with recurrent abdominal pain showed significantly higher rates of open Petersen's space compared to the group of patients with other preoperative diagnoses. Preoperative body mass index (BMI) less than 40kg/m2 at time of LRYGB was associated with a higher risk for an open MD. At least one MD reopened in almost half of the patients despite routine closure during LRYGB. Therefore, the status of MDs should be routinely examined during every reoperation after LRYGB and closure of open MDs should be performed.

Assessing outcomes in laparoscopic vs open surgical management of adhesive small bowel obstruction.

Small bowel obstruction is typically managed nonoperatively; however, refractory small bowel obstructions or closed loop obstructions necessitate operative intervention. Traditionally, laparotomy has long been the standard operative intervention for lysis of adhesions of small bowel obstructions. But as surgeons become more comfortable with minimally invasive techniques, laparoscopy has become a widely accepted intervention for small bowel obstructions. The objective of this study was to compare the outcomes of laparoscopy to open surgery in the operative management of small bowel obstruction. This is a retrospective analysis of operative small bowel obstruction cases at a single academic medical center from June 2016 to December 2019. Data were obtained from billing data and electronic medical record for patients with primary diagnosis of small bowel obstruction. Postoperative outcomes between the laparoscopic and open intervention groups were compared. The primary outcome was time to return of bowel function. Secondary outcomes included length of stay, 30-day mortality, 30-day readmission, VTE, and reoperation rate. The cohort consisted of a total of 279 patients with 170 (61%) and 109 (39%) patients in the open and laparoscopic groups, respectively. Patients undergoing laparoscopic intervention had overall shorter median return of bowel function (4 vs 6days, p = 0.001) and median length of stay (8 vs 13days, p = 0.001). When stratifying for bowel resection, patients in the laparoscopic group had shorter return of bowel function (5.5 vs 7days, p = 0.06) and shorter overall length of stay (10 vs 16days, p < 0.002). Patients in the laparoscopic group who did not undergo bowel resection had an overall shorter median return of bowel function (3 vs 5days, p < 0.0009) and length of stay (7 vs 10days, p < 0.006). When comparing surgeons who performed greater than 40% cases laparoscopically to those with fewer than 40%, there was no difference in patient characteristics. There was no significant difference in return of bowel function, length of stay, post-operative mortality, or re-admission laparoscopic preferred or open preferred surgeons. Laparoscopic intervention for the operative management of small bowel obstruction may provide superior clinical outcomes, shorter return of bowel function and length of stay compared to open operation, but patient selection for laparoscopic intervention is based on surgeon preference rather than patient characteristics.