Early Small Bowel Obstruction Research Articles

Long-term mesh-related complications from minimally invasive intraperitoneal onlay mesh for small to medium-sized ventral hernias

IntroductionIntraperitoneal onlay mesh (IPOM) placement for small to medium-sized hernias has garnered negative attention due to perceived long-term risk of mesh-related complications. However, sparse data exists supporting such claims after minimally invasive (MIS) IPOM repairs and most is hindered by the lack of long-term follow-up. We sought to report long-term outcomes and mesh-related complications of MIS IPOM ventral hernia repairs.Methods and proceduresAdult patients who underwent MIS IPOM ventral hernia repair at our institution were identified in the Abdominal Core Health Quality Collaborative database from October 2013 to October 2020. Outcomes included hernia recurrence and mesh-related complications or reoperations up to 6 years postoperatively.ResultsA total of 325 patients were identified. The majority (97.2%) of cases were elective, non-recurrent (74.5%), and CDC class I (99.4%). Mean hernia width was 4.16 ± 3.86 cm. Median follow-up was 3.6 (IQR 2.8–5) years. Surgeon-entered or patient-reported follow-up was available for 253 (77.8%) patients at 3 years or greater postoperatively. One patient experienced an early small bowel obstruction and was reoperated on within 30 days. Two-hundred forty-five radiographic examinations were available up to 6 years postoperatively. Twenty-seven patients had hernia recurrence on radiographic examination up to 6 years postoperatively. During long-term follow-up, two mesh-related complications required reoperations: mesh removed for chronic pain and mesh removal at the time of colon surgery for perforated cancer. Sixteen additional patients required reoperation within 6 years for the following reasons: hernia recurrence (n = 5), unrelated intraabdominal pathology (n = 9), obstructed port site hernia (n = 1), and adhesive bowel obstruction unrelated to the prosthesis (n = 1). The rate of reoperation due to intraperitoneal mesh complications was 0.62% (2/325) with up to 6 year follow-up.ConclusionIntraperitoneal mesh for repair of small to medium-sized hernias has an extremely low rate of long-term mesh-related complications. It remains a safe and durable option for hernia surgeons.

Small bowel obstruction secondary to barbed sutures in bariatric surgery: a cautionary tale.

Laparoscopic bariatric surgery relies on technically challenging intracorporeal suturing for critical parts of the operation. Barbed sutures have been developed to provide an alternative to suturing for certain manoeuvres within a procedure. Barbed sutures theoretically negate the need for knot tying and allow for continuous application of tension; however the barbs can unintentionally adhere to surrounding tissues. We describe a case series of three patients who developed V-Loc™ (barbed) suture related small bowel obstruction (SBO) to promote awareness of this unusual but preventable complication. Medical records of patients diagnosed with V-Loc™ related SBO between 2018 and 2021 at a tertiary centre were reviewed. Data regarding presentation, diagnosis, management and outcomes were obtained. Three patients were identified where V-Loc™ sutures were aetiologically related to early post-surgical small bowel obstruction secondary to small bowel adherence to barbed suture tail or adhesions between barbed suture tail and unintended viscera. In these cases, non-absorbable V-Loc™ sutures were used to close the small bowel mesenteric defect at Roux-en-Y gastric bypass surgery. All patients required adhesiolysis at re-look laparoscopy prior to resolution. All patients were discharged home well after relook laparoscopy. Overly long or exposed V-Loc™ suture tails can result in SBO following laparoscopic bariatric surgery. Cutting the suture tail as close as practical to the final throw of the suture and/or covering exposed suture ends may prevent this complication.

Early small bowel obstruction as a complication of abdominal drain in colon cancer surgery: a case report and literature review

Introduction: Early postoperative small bowel obstruction (EPSBO) is an obstruction that occurs within 4 weeks after the initial surgery. Routine prophylactic abdominal drainage does not provide any benefit in colon cancer surgery. The cause of EPSBO due to the abdominal drainage tube is infrequent. Case presentation: A 72-year-old male patient was diagnosed with sigmoid carcinoma and underwent laparoscopic left colectomy. A surgical drain was placed in the pouch of Douglas through the incision of the right iliac fossa trocar site. On the fourth day, he began to flatus, and the abdominal pain decreased. However, on the ninth day after surgery, the patient had more abdominal pain, could not pass gas and defecate, and the abdomen was more distended. An abdominal computed tomography (CT) scan showed a dilated loop of the small intestine above the transition site with a drainage sonde and no dilation of the loop below the sonde. The patient was indicated to remove the sonde. He could pass gas and defecate the next day again and was relieved of the abdominal distention. Discussion: Once an EPSBO is considered, it is essential to think of the bowel obstruction caused by the drainage tube in the case of abdominal drainage. It is necessary to have a contrast CT scan to examine. Conclusion: EPSBO due to intra-abdominal drainage is a rare condition that presents a challenge in diagnosis and treatment. Diagnosis usually begins on the fourth postoperative day, mainly in operations in the lower transverse mesentery, including drainage placement after laparoscopic surgery.

Adhesive small-bowel obstruction: Conservative versus surgical management?

Bowel obstruction is a common emergency requiring acute medical care. Small-bowel obstruction (SBO) accounts for 80% of all mechanical bowel obstruction, and adhesive SBO is the most common cause of SBO. Computed tomography imaging in patients with abdominopelvic surgery history is useful to diagnose adhesive SBO (ASBO), to exclude other causes of SBO, and to identify patients who need emergency surgeries which usually are closed-loop obstruction, strangulated obstruction, or perforation. For uncomplicated ASBO, the timing when surgery has always existed controversy. Studies revealed that prolonged nonoperative management is associated with increased morbidity. On the other hand, operative management of ASBO may decrease the risk of recurrence. During the conservative management for patients who do not need emergency surgeries, gastrografin challenge may accelerate relief from obstruction and avoid unnecessary surgery, or promote surgical decision-making and avoid delayed surgery. In addition, early postoperative SBO (EPSBO) with adhesive or inflammatory causes and unresectable malignant bowel obstruction should be identified and avoided surgery, although these patients have past abdominopelvic surgery history.

Association between appendiceal stump closure method and post-operative bowel obstruction after laparoscopic appendectomy

BackgroundLaparoscopic appendectomy is one of the most common urgent pediatric surgical operations. Endoscopic surgical staplers and pre-tied endoloop ligatures are both routinely used for closure of the appendiceal stump in children. Practice patterns vary for a number of reasons, including cost, size, and ease of use. While stapling is standard for some pediatric surgeons, others believe that staples can act as a nidus for small bowel obstruction (SBO). However, studies comparing closure methods have been conflicting in their results and limited in size. Therefore, we aim to determine if there is an association between appendiceal stump closure method and SBO using a national comparative pediatric database. MethodsWe queried the Pediatric Health Information System (PHIS) for patients ages 3–18 years who underwent laparoscopic appendectomy for appendicitis between 1/1/2016 – 12/31/2020. We included hospitals that had greater than 50 patients with billing data and excluded patients with inflammatory bowel disease and simultaneous abdominal operations. We used billing data for the patient's appendectomy to determine if a stapler or a suture ligature was used during the case. Our primary outcome of interest was post-operative SBO or reoperation for lysis of adhesion or intestinal surgery within the first 30 post-operative days. Multivariable regression analyses were used to estimate the association between stump closure method and post-operative SBO or reoperation in addition to cost while adjusting for patient demographics and appendiceal perforation. ResultsIn total, 49,191 patients from 37 hospitals were included, of which, 29,733 (60.44%) were male, 21,403 (43.51%) were non-Hispanic white, and 18,291 (37.18%) had a diagnosis of complicated appendicitis. The median [IQR] age of the cohort was 11 [8–14] years. A surgical stapler was used during laparoscopic appendectomy in 35,788 (72.75%) patients, and early SBO or reoperation occurred in 653 (1.33%) patients. In adjusted analysis controlling for demographics and complicated appendicitis there was no statistically significant difference in the odds of SBO or reoperation between the two groups. (OR 1.17; 99% CI 0.86 – 1.6). Complicated appendicitis was the factor most associated with post-operative SBO or reoperation (OR 4.4; 99% CI 3.01 – 6.44). Median cumulative cost was slightly higher on unadjusted analysis in the stapler group ($10,329.3 vs $9,569.2). However, there was no significant difference on adjusted analysis. ConclusionSBO or reoperation following laparoscopic appendectomy for appendicitis is uncommon. Complicated appendicitis is the most predictive factor of this outcome. Adjusting for available patient, disease, and hospital characteristics, use of a surgical stapler does not appear to be meaningfully associated with the development of acute SBO or reoperation. Surgeon preference remains the mainstay for safe appendiceal stump closure method. Level of evidenceLevel III. Study typeRetrospective Comparative Study.

BS O01 Closure of mesenteric defects during laparoscopic roux-en-y gastric bypass surgery and its effect on internal hernia rates and small bowel obstruction: A Meta- Analysis

Abstract Background Roux-en-Y gastric bypass surgery is an important treatment for obesity and it's related diseases, however internal herniation and small bowel obstruction from mesenteric defects can lead to reoperation in 10–16% of patients. This can be early (<30 days) or late. Routine closure of meso-jejunal defecfs and/or Petersens defect is still not adopted worldwide. Our objective was to systematically review and analyse pooled data from all studies, evaluating the impact of routine closure of mesenteric defects on the incidence of internal hernia in laparoscopic antecolic Roux-en-Y gastric bypass (RYGB) surgery for obesity. Secondary endpoints for analysis included the incidence of early and late small bowel obstruction (SBO), need for reoperation, bleeding, anastomotic leak, marginal ulceration and weight loss. Methods Ovid, MEDLINE, EMBASE and Cochrane databases were searched on 13 September 2021 using a combination of MeSH and non-MeSH terms, including ‘gastric bypass’, ‘mesenteric defect’, ‘hernia’, and ‘small bowel obstruction’. Studies comparing closure with non-closure of mesenteric defects were included. Two researchers independently examined titles, then abstracts, and finally, full text articles. Disagreements were arbitrated with the senior author. Fixed- or random-effect models were used, as appropriate. Results have been reported with 95% confidence intervals and I-squared indices to assess uniformity among results for each outcome measured. Results Seventeen studies met the criteria and were included, including two randomised trials. A total of 61,220 patients were included with follow-up ranging from 24–120 months. In the closure group the incidence of all types of internal hernia was lower (OR 0.22, 95% CI 0.19, 0.26), SBO beyond 30 days was less frequent (OR 0.47, 95% CI 0.44,0.52), and the reoperation rate was lower (OR 0.22, 95% CI 0.19,0.26). The incidence of SBO within 30 days was higher in the closure group (OR 1.34, CI 1.07,1.68). Conclusions This new pooled analysis updates previous meta-analyses, adding data from eight additional studies and almost 45,000 additional patients. This provides firm evidence that routine closure of mesenteric defects during laparoscopic gastric bypass reduces rates of internal herniation and SBO beyond the post-operative period. Closure of the mesenteric defects should be standard practice in RYGB. A higher incidence of early SBO was notable in the closure group, postulated by some studies as attributable to technical factors, including kinking of the jejunal anastomosis and bleeding. This must be considered when closing defects.

Novel nomogram for predicting risk of early postoperative small bowel obstruction after right colectomy\xa0for cancer

BackgroundEarly postoperative small bowel obstruction (EPSBO) is a common complication after colorectal cancer surgery. Few studies have specifically studied risk factors for early small bowel obstruction after right colectomy, especially in establishing predictive models. The purpose of the current study was to establish an effective nomogram to predict the incidence of EPSBO after right colectomy.MethodsThe current study retrospectively analyzed data from a total of 424 patients who underwent right colectomy in a local hospital from January 2014 to March 2021. A logistic regression model was used to identify potential risk factors for EPSBO after right colectomy. A nomogram was established by independent risk factors, and the prediction performance of the model was evaluated using an area under the receiver operating characteristic (ROC) curve and calibration chart.ResultsA total of 45 patients (10.6%) developed early small bowel obstruction after right colectomy. Male sex, history of abdominal surgery, open surgery, long operative time, anastomotic leakage, and preoperative albumin were closely related to EPSBO. Analysis of postoperative rehabilitation indices showed that EPSBO remarkably slowed the postoperative rehabilitation speed of patients. Multivariate logistic regression analysis showed that male sex, open surgery, operative time, and anastomotic leakage were independent risk factors (P < 0.05), and the operation time had the greatest impact on EPSBO. On the basis of multivariate logistic regression, a nomogram was constructed, which showed moderate accuracy in predicting EPSBO, with a C-statistic of 0.716. The calibration chart showed good consistency between the predicted probability and ideal probability.ConclusionThe current study constructed a nomogram based on the clinical data of patients who underwent right colectomy, which had moderate predictability and could provide reference value for clinicians to evaluate the risk of EPSBO.

10 Small bowel entrapment during pelvic reconstructive surgery

The objectives of this video are to describe a case of a small bowel strangulation resulting from bowel entrapment within a uterosacral ligament suspension (USL) suture, to discuss the pathophysiology of small bowel obstruction (SBO), to discuss early recognition of this rare complication, and to recommend practice changes that may help prevent small bowel entrapment during USL procedures. This video presents a case of a small bowel strangulation resulting from bowel entrapment within a uterosacral ligament suspension suture. After reviewing the literature pertaining to the incidence of early small bowel obstruction in gynecology, we will discuss our patient's clinical presentation with a focus on her CT imaging and findings on diagnostic laparoscopy. Next, we use original illustrations throughout the video to illustrate the pathophysiology of small bowel obstruction, closed loop obstructions, and bowel strangulation. Finally, using original illustrations, we discuss practice changes which we have adopted to prevent this rare complication. Through this video we hope to teach clinicians about the presentation and Croton pathophysiology of closed loop small bowel obstruction, which are uncommon complications following uterosacral ligament colpopexy. We hope that this video will encourage clinicians to maintain a very high index of suspicion for this complication in patients who present with obstructive symptoms in the acute postoperative period following a uterosacral ligament colpopexy. In addition to suture removal, we emphasize that abdominal exploration with bowel examination is essential as a necrotic segment of bowel warrants urgent intervention with excision and anastomosis. Through this video we hope to teach clinicians about the presentation and pathophysiology of closed loop small bowel obstruction, which are uncommon complications following uterosacral ligament colpopexy. We hope that this video will encourage clinicians to maintain a very high index of suspicion for this complication in patients who present with obstructive symptoms in the acute postoperative period following a uterosacral ligament colpopexy. In addition to suture removal, we emphasize that abdominal exploration with bowel examination is essential as a necrotic segment of bowel warrants urgent intervention with excision and anastomosis.

Risk factors for readmission for early small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: an MBSAQIP analysis

Abstract Background Small bowel obstruction (SBO) following laparoscopic Roux-en-Y gastric bypass (LRYGB) is associated with significant morbidity. Objectives To evaluate the rate of and risk factors for readmission for SBO within 30 days of LRYGB. Setting Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)–accredited centers. Methods This is a retrospective study using the MBSAQIP database. A query was performed from 2015–2018 for patients who underwent LRYGB and required readmission for SBO. Those who had a reoperation, intervention, readmission, or expired from causes other than SBO were excluded. Descriptive, bivariate, and binary logistic regression analyses were performed. Results Among 184,660 patients undergoing LRYGB, 1189 (.64%) required readmission due to SBO. Among the readmission cases, 978 (82.5%) were identified as having intestinal obstruction (unspecified), 108 (9.1%) incisional hernia, and 100 (8.4%) internal hernia. Among these cases, 69% had a reoperation and 1.3% expired during the 30-day period. From a logistic regression model, parameters independently associated with an increased risk for readmission for early SBO include being female (adjusted odds ratio [AOR], 1.53) or black (AOR, 1.41) and having gastroesophageal reflux (AOR, 1.35), a history of myocardial infarction (AOR, 1.76), a history of deep vein thrombosis (AOR, 1.73), previous obesity surgery/foregut surgery (AOR, 1.79), a robotic-assisted procedure (AOR, 1.23), concurrent hiatal hernia repair (AOR, 1.66) and adhesiolysis (AOR, 1.42). Conclusion The rate of readmission for early SBO following LRYGB was less than 1%. The majority of these cases required reoperation. The increased intraoperative complexity of LRYGB is associated with an increased risk of readmission due to early SBO.

Short-term outcomes of parastomal hernia prophylaxis with Stapled Mesh stomA Reinforcement Technique (SMART) in permanent stomas.

Parastomal hernias occur in 50-80% after stoma formation. Even with mesh repairs, recurrence can be as high as 33%. Stapled Mesh stomA Reinforcement Technique (SMART) places a prophylactic onlay mesh in the trephine during permanent stoma formation to prevent parastomal hernia. Our study aims to describe the short-term outcomes of SMART procedures. A prospective study of patients receiving the SMART procedure from 2015 to 2020 was conducted. non-Crohn's colorectal and urological surgery with permanent stoma formation. The SMART surgical technique incorporates a 70-mm circular piece of polypropylene mesh by stapling it to the muscular abdominal wall using a circular stapler, and attaching the edge of the mesh to the deep fascia. Fifty patients had a total of 53 SMART procedures. Median follow-up was 27 months. Procedures included: 35 end colostomies, five end ileostomies, eight ileal urinary conduits and five double-barrelled wet colostomies. Four patients had parastomal hernia during follow-up. One was acute, on day 1, due to very large size of trephine, one in a double-barrelled wet stoma that was repaired laparoscopically, one had a stomal prolapse requiring revision at 3 years and one patient had early small bowel obstruction due to very small size of trephine requiring another surgery. There were no wound infections or mesh-related sepsis. Symptomatic parastomal herniation occurred in 8% of the study population, and most complications were due to incorrect choice of stapled trephine diameter. Longer term follow-up is required to assess for problematic parastomal hernia.

Early Postoperative Small Bowel Obstruction After Appendectomy Because of Staples in Pediatric Patients

BackgroundPostoperative small bowel obstruction (SBO) is an important complication of laparoscopic appendectomy in children, resulting in readmission and potential for intestinal loss. We reviewed our experience with early postoperative SBO. MethodsA retrospective review was performed of patients undergoing an appendectomy with subsequent SBO from 2014 to 2018. Patients were excluded if a concurrent gastrointestinal procedure was done during the appendectomy, or if they had previous abdominal surgery. ResultsOf 793 appendectomies performed at our institution during the study period, only six patients met the inclusion criteria for our chart review (7.6 SBO per 1000 appendectomies), ranging in age from 4 to 19 y. Four patients had uncomplicated appendicitis, and all underwent laparoscopic appendectomy within 24 h. Five were discharged postoperatively, with one patient remaining hospitalized for persistent ileus. Median time to representation with SBO was 7 d (range, 2-37). Three patients had indications for urgent exploration and underwent re-exploration shortly after presentation. Three patients underwent initial nonoperative management, but subsequently, all patients failed to progress and required operative exploration. Staples were found to be the culprit lesion in four of six patients, all of which notably initially presented with uncomplicated appendicitis, with two patients found to have ischemic bowel at the time of exploration. ConclusionsAlthough rare, pediatric patients with SBO soon after laparoscopic appendectomy should be considered for early operative management, especially if the appendicitis was uncomplicated. When staples are used for appendectomy, stray staples should not be left as they can serve as a nidus for obstruction.

Fluoroscopic balloon dilation for early jejunojejunostomy obstruction after gastrectomy with roux-en-Y reconstruction: a case series of three patients

BackgroundSmall bowel obstruction after gastrectomy with Roux-en-Y reconstruction (R-Y reconstruction) is not a rare complication. However, patients who need re-operation for this complication have a high rate of postoperative complications.We report a case series of three patients who underwent fluoroscopic balloon dilation (FBD) for early jejunojejunostomy obstruction (JJO) after gastrectomy with Roux-en-Y reconstruction (R-Y reconstruction).Case presentationThree patients were referred to our hospital for surgery for gastric cancer. Robot-assisted distal gastrectomy with D2 lymph node dissection and antecolic R-Y reconstruction were performed in two patients, and robot-assisted total gastrectomy with D1+ lymph node dissection and antecolic R-Y reconstruction was performed in one patient. The jejunojejunostomy was created as a side-to-side anastomosis using a linear 45-mm stapler. The entry hole was closed with a knotless barbed suture, and serosal-muscle layer suture reinforcement with an absorbable suture was performed at the jejunojejunostomy.Subsequently, all the patients were diagnosed with JJO by computed tomography and upper gastrointestinal series. The average time to JJO from gastrectomy was 5 days (range 2–7); initial clinical symptoms were vomiting in all three cases, with simultaneous upper abdominal pain in one case. We successfully performed FBD in all three cases after unsuccessful conservative treatment using an ileus tube. The clinical symptoms improved soon after FBD, and all the patients were able to avoid re-operation. The average period to FBD from JJO was 10 days (range 4–14). The average procedure time was 46 min (range 29–68), and the average duration to oral intake from FBD was 4 days (range 2–5). The average duration of hospital stay after FBD was 12 days (range 9–15). There were no complications in any of the cases.ConclusionFBD might be a feasible procedure to avoid surgery for early small bowel obstruction after gastrectomy with R-Y reconstruction.

Closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: a systematic review and meta-analysis.

The comparative evidence regarding the outcomes of closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass (LRYGB) is poorly understood. We aimed to compare the outcomes of closure versus non-closure of mesenteric defects in LRYGB for morbid obesity. We conducted a search of electronic information sources to identify all comparative studies investigating the outcomes of closure versus non-closure of mesenteric defects in patients undergoing LRYGB for morbid obesity. We used the Cochrane risk of bias tool and the ROBINS-I tool to assess the risk of bias of RCTs and observational studies, respectively. Random or fixed effects modelling was applied as appropriate. We included 10,031 patients from six observational studies and 2609 patients from two RCTs. Analysis of observational studies showed closure defects resulted in lower risks of internal hernia (OR 0.28, 95% CI 0.15, 0.54) and reoperation for small bowel obstruction (SBO) (OR 0.30, 95% CI 0.10, 0.83); no difference was found between the two groups in terms of SBO not related to internal hernia (OR 1.19, 95% CI 0.47, 2.99), early SBO (OR 0.74, 95% CI 0.04, 14.38), anastomotic leak (OR 0.84, 95% CI 0.45, 1.57), bleeding (OR 1.08, 95% CI 0.62, 1.89), and anastomotic ulcer (OR 2.08, 95% CI 0.62, 6.94). Analysis of RCTs showed closure of defects resulted in lower risks of internal hernia (OR 0.29, 95% CI 0.19,0.45) and reoperation for SBO (OR 0.51, 95% CI 0.38, 0.69) but higher risks of SBO not related to internal hernia (OR 1.90, 95% CI 1.09, 3.34) and early SBO (OR 2.63, 95% CI 1.16, 5.96); no difference was found between the two groups in terms of anastomotic leak (OR 1.95, 95% CI 0.80, 4.72), bleeding (OR 0.67, 95% CI 0.38, 1.17), and anastomotic ulcer (OR 2.08, 95% CI 0.62, 6.94). Our results suggest that closure of mesenteric defects in LRYGB may be associated with lower risks of internal herniation and reoperation for SBO compared with non-closure of the defects (moderate certainty). The available evidence is inconclusive regarding the risks of SBO not related to internal hernia and early SBO (low certainty). More RCTs are needed to improve the robustness of the available evidence.

One-stage operation without intraoperative colonic irrigation for left-sided colonic obstruction: Case series study

BackgroundTo perform a one-stage operation safely in selected patients with left-sided colonic obstruction, many surgeons have considered intraoperative colonic irrigation as an indispensable step. Recently, studies have shown that step is unnecessary. The aim of this study was to identify the early results of a one-stage operation without intraoperative colonic irrigation in the treatment of left-sided colonic obstruction. MethodsThis case series included patients who had resectable left-sided colonic obstruction and were admitted to Nhan Dan Gia Dinh Hospital from January 2008 to December 2018. All patients were treated by one-stage operation without intraoperative colonic irrigation. The early results were described, focusing on mortality, anastomotic-related complications, operative time and length of hospital stay. ResultsThere were 74 patients with a mean age of 50 years (range 20–81 years). Colorectal cancer accounted for 86.4% of cases. The median operative time was 158 ± 42 min (range 65–285 min). One patient (1.4%) died on postoperative day 6 due to pneumonia and multiorgan failure. Three patients (4.1%) had major anastomotic leakage, 4 patients (5.4%) had minor anastomotic leakage, 9 patients (12.2%) had wound infection, 4 patients (5.4%) had intraabdominal fluid collection, and 1 patient (1.4%) had an early adhesive small bowel obstruction. The median length of hospital stay was 9 ± 3 days (range 5–24 days). The method was successful in 70/74 patients (94.6%). ConclusionsWith properly selected patients and experienced GI surgeons, a one-stage operation without intraoperative colonic irrigation is an effective and safe alternative for resectable left-sided colonic obstruction.

32: Incidence and risk factors of early post-operative small bowel obstruction in patients undergoing hysterectomy for benign indications

The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO), occurring within the first month of surgery, after benign hysterectomy. This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Patient demographics, clinical and surgical factors were obtained. Patients were then stratified into those with and without and SBO. Differences between groups were evaluated using Chi-squared and Fisher’s exact tests for categorical variables, and the Student’s t-test for continuous variables. Multivariable logistic regression was used to identify significant independent predictors of SBO. There were 286 (0.06%) occurrences of SBO out of 47,937 hysterectomies. Patients experiencing SBO were more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, p<0.001), LOA (5.2% vs 2.1%, p<0.001), appendectomy (1.7% vs 0.5%, p=0.02), and cystotomy repair (1.0% vs 0.3%, p= 0.002). After logistic regression, mode of hysterectomy was not a significant predictor of SBO, while contaminated and infected wounds (aOR=5.93, 95% CI: 2.71-12.96) and perioperative transfusion (aOR=5.21, 95% CI: 3.66-7.29) were the most significant risk factors. Additional risk factors for early SBO included non-white race (aOR= 1.83, 95% CI: 1.34-2.48), older age (aOR=1.03, 95% CI: 1.02-1.05), prior abdominal or pelvic surgery (aOR=1.45, 95% CI: 1.26-2.60), operating times exceeding 170 minutes (aOR=1.90, 95% CI: 1.39-2.59), uterine weight greater than 250 grams (aOR=1.54, 95% CI: 1.11-2.14), lysis of adhesions (aOR=2.12, 95% CI: 1.24-3.66), and concurrent appendectomy (aOR=2.98, 95% CI: 1.20-7.41). Early small bowel obstruction is a rare complication of benign hysterectomy and is unrelated to route of hysterectomy after adjusting for confounders. Multiple risk factors related to abdomino-pelvic adhesive disease were associated with a higher risk of bowel obstruction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Incidence and risk factors of early postoperative small bowel obstruction in patients undergoing hysterectomy for benign indications

Small bowel obstruction (SBO) is a major cause of postoperative mortality and morbidity following abdominal and pelvic surgery, with 225,000-345,000 annual admissions. SBO may be classified based on onset from day of surgery. Early SBO occurs within the first 30 days following surgery, whereas late SBO occurs after the initial 30-day postoperative window. The majority of either type of bowel obstruction is believed to be secondary to intra-abdominal adhesions. Early SBO warrants special attention because of the difficulty in distinguishing between mechanical and nonmechanical obstruction during this period. Whereas conservative management often leads to resolution of nonmechanical obstruction and some partial SBO, surgical management is associated with a higher rate of complications compared to surgery for late SBO because of the presence of hypervascular adhesions in the early postoperative period. The current literature regarding SBO, and early SBO in particular, following hysterectomy is limited. Given that approximately 400,000 hysterectomies are performed annually, understanding the risk factors associated with SBO following these types of surgeries is imperative for improving patient outcomes. The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO) after hysterectomy for benign indications. This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Data on patient demographics and clinical and surgical factors were obtained. Patients were then stratified into those with and those without SBO. Pairwise comparison was performed using the Wilcoxon rank-sum test and Fisher exact tests. Multivariable logistic regression was used to identify significant independent predictors of SBO. Of 47,937 hysterectomies, SBO occurred in 286 patients, at a rate of 5.9 per 1000 hysterectomies. Comparing patients with and without SBO, those with an obstruction were older (49 vs 46 years, P<.001) and were more likely to smoke (21.0% vs 15.8%, P= .02), to have a history of prior abdominal surgery (73.4% vs 65.4%, P= .005), and to have medical comorbidities such as hypertension and dyspnea. Patients experiencing SBO were also more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, P < .001), adhesiolysis (5.2% vs 2.1%, P < .001), appendectomy (1.7% vs 0.5%, P= .02), and cystotomy repair (1.0% vs 0.3%, P= .002). After logistic regression, route of hysterectomy was not a significant risk factor for SBO, whereas wound class ≥3 (adjusted odds ratio [aOR], 5.96; 95% confidence interval [CI], 2.71-12.99) and perioperative transfusion (aOR, 5.01; 95% CI, 3.54-7.13) were the most significant risk factors. Additional risk factors for early SBO included nonwhite race (aOR, 1.84; 95% CI, 1.33-2.48), increasing age (aOR, 1.04; 95% CI, 1.02-1.05), prior abdominal or pelvic surgery (aOR, 1.49; 95% CI, 1.17-2.03), operating times >170 minutes (aOR, 1.90; 95% CI, 1.37-2.58), uterine weight >250 g (aOR, 1.54; 95% CI, 1.11-2.14), lysis of adhesions (aOR, 2.10; 95% CI, 1.23-3.66), and concurrent appendectomy (aOR, 2.64; 95% CI, 1.06-6.65). Early SBO is a rare complication of benign hysterectomy. Although route of hysterectomy was not found to be a significant risk factor for early SBO, variables typically associated with abdominal hysterectomy compared to minimally invasive hysterectomy, including higher wound class, larger uteri, and perioperative transfusion (a marker of intraoperative blood loss), were strongly correlated with subsequent development of early obstruction.

Impact of mesenteric defect closure technique on complications after gastric bypass

BackgroundClosure of mesenteric defects during laparoscopic gastric bypass surgery markedly reduces the risk for small bowel obstruction due to internal hernia. However, this procedure is associated with an increased risk for early small bowel obstruction and pulmonary complication. The purpose of the present study was to evaluate whether the learning curve and subsequent adaptions made to the technique have had an effect on the risk for complications.MethodsThe results of patients operated with a primary laparoscopic gastric bypass procedure, including closure of the mesenteric defects with sutures, during a period soon after introduction (January 1, 2010–December 31, 2011) were compared to those of patients operated recently (January 1, 2014–June 30, 2017). Data were retrieved from the Scandinavian Obesity Surgery Registry (SOReg). The main outcome was reoperation for small bowel obstruction within 30 days after surgery.ResultsA total of 5444 patients were included in the first group (period 1), and 1908 in the second group (period 2). Thirty-day follow-up rates were 97.1 and 97.5% respectively. The risk for early (within 30 days) small bowel obstruction was lower in period 2 than in period 1 (13/1860, 0.7% vs. 67/5285, 1.3%, OR 0.55 (0.30–0.99), p = 0.045). The risk for pulmonary complication was also reduced (5/1860, 0.3%, vs. 41/5285, 0.8%, OR 0.34 (0.14–0.87), p = 0.019).ConclusionClosure of mesenteric defects during laparoscopic gastric bypass surgery can be performed safely and should be viewed as a routine part of that operation.

Early Small Bowel Obstruction in a 9-Year Old Boy After Laparoscopy and Minilaparotomy Due to Traumatic Small Bowel Perforation

Early Small Bowel Obstruction in a 9-Year Old Boy After Laparoscopy and Minilaparotomy Due to Traumatic Small Bowel Perforation

Bidirectional Jejunojejunal Anastomosis Prevents Early Small Bowel Obstruction Due to the Kinking After Closure of the Mesenteric Defect in the Laparoscopic Roux-en-Y Gastric Bypass.

The closure of the mesenteric defects (CMD) in Roux-en-Y gastric bypass (RYGB) reduces the risk of small bowel obstruction (SBO) due to internal hernia but might be associated with an increased risk of early SBO triggered by the jejunojejunal anastomosis (JJS) kinking. The aim of this study was to assess how enlarging the JJS with a bidirectional linear stapling can aid in avoiding the risk of early SBO by kinking. This retrospective cohort study concerns 1327 patients who underwent RYGB with CMD between May 2007 and August 2016. The first 626 patients (group A) had a unidirectional JJS. The following 701 patients (group B) had a bidirectional side-to-side JJS and a hand-sewn closure of the remaining defect. We compared early SBO between the two groups. Eleven (1.75%) early SBO due to the JJS kinking occurred in group A, whereas none occurred in group B (p = 0.0012). Thirty-nine early postoperative complications happened in group A versus 32 in group B (p = 0.17). Nine (1.2%) digestive bleedings occurred in group B versus two (0.3%) in group A (OR = 4.05 [0.87-18], p = 0.054). Average operating time was 81min [37-330] in group A and 77min [33-240] in group B. Enlarging the JJS with a bidirectional linear stapling is associated with a reduced risk of early SBO due to the anastomosis kinking. However, it could be related to an increased risk of digestive bleedings.

Recognition of the diagnosis and treatment of small intestinal obstruction

Small intestinal obstruction is a common and frequent disease in general surgery. Delayed diagnosis and surgical timing, and inaccurate treatment strategy will lead to life-threatening complications. Therefore, how to diagnose and treat quickly and accurately is still a difficult problem in current gastrointestinal surgery. This paper summarizes and analyzes the diagnosis and treatment strategies of small intestinal obstruction based on current laboratory technology, medical imaging technology, perioperative management and improvement of surgical concepts. At the same time, early postoperative inflammatory small bowel obstruction, radioactive enteritis with intestinal obstruction, primary abdominal cocoon, primary pseudo obstruction are discussed according to the long-term experience of the author's department. The aim is to establish a reasonable and effective strategy for the diagnosis and treatment of common and special small intestinal obstruction.