Episodes Of Small Bowel Obstruction Research Articles

A new clinical severity score for the management of acute small bowel obstruction in predicting bowel ischemia: a cohort study.

Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a nonviable small bowel remains a challenge. Through a prospective cohort study, the authors aimed to validate risk factors and scores for intestinal resection, and to develop a practical clinical score designed to guide surgical versus conservative management. All patients admitted for an acute SBO between 2004 and 2016 in the center were included. Patients were divided in three categories depending on the management: conservative, surgical with bowel resection, and surgical without bowel resection. The outcome variable was small bowel necrosis. Logistic regression models were used to identify the best predictors. Seven hundred and thirteen patients were included in this study, 492 in the development cohort and 221 in the validation cohort. Sixty-seven percent had surgery, of which 21% had small bowel resection. Thirty-three percent were treated conservatively. Eight variables were identified with a strong association with small bowel resection: age 70 years of age and above, first episode of SBO, no bowel movement for greater than or equal to 3 days, abdominal guarding, C-reactive protein greater than or equal to 50, and three abdominal computer tomography scanner signs: small bowel transition point, lack of small bowel contrast enhancement, and the presence of greater than 500ml of intra-abdominal fluid. Sensitivity and specificity of this score were 65 and 88%, respectively, and the area under the curve was 0.84 (95% CI: 0.80-0.89). The authors developed and validated a practical clinical severity score designed to tailor management of patients presenting with an SBO.

Difficult to Diagnose the Cause of Intestinal Obstruction due to Abdominal Cocoon Syndrome.

Abdominal cocoon syndrome is rare condition with repeated episodes of intestinal obstruction.Radiological investigations combined with a high index of suspicion are mandatory for establishing the diagnosis.Proper and timely diagnosis can lead to successful conservative treatment.

Does Laparoscopic Adhesiolysis Reduce the Risk of Small Bowel Obstruction Related Readmissions and Reoperations Compared to Open Adhesiolysis?

PurposeThe present study aimed to assess the safety and efficacy of laparoscopic adhesiolysis in decreasing recurrent episodes of small bowel obstruction (SBO) compared to that of the conventional open procedure.MethodsAmong 373 patients who visited our emergency department from January 2000 to July 2018 due to small bowel obstruction, 67 patients who underwent adhesiolysis were included in this study. Eighteen and 49 patients comprised the open adhesiolysis (OA) and laparoscopic adhesiolysis (LA) groups, respectively. Clinical demographics, computed tomography (CT) findings, laboratory results, and perioperative outcomes were compared. Further, the long-term follow-ups of SBO related re-admissions and re-operations were also compared.ResultsPreoperative baseline data, pain characteristics, laboratory findings, and ileus-related CT findings showed no significant difference between the two groups. LA was related to less blood loss and complications, along with early bowel movement recovery. Similarly, fewer SBO-related re-admissions [OA vs. LA=8 (44.4%) vs. 3 (6.1%), p=0.001] and re-operations [OA vs. LA=3 (16.7%) vs. 1 (2.0%), p=0.025] were observed in LA compared to OA.ConclusionLA is a safer and more feasible procedure for SBO treatment compared to OA. This procedure showed a reduction in SBO-related re-admission and re-operation rates.

A Successful Treatment of Encapsulating Peritoneal Sclerosis in an Adolescent Boy on Long-term Peritoneal Dialysis: A Case Report

Encapsulating peritoneal sclerosis (EPS) is a rare life-threatening complication associated with peritoneal dialysis (PD). EPS is characterized by progressive fibrosis and sclerosis of the peritoneum, with the formation of a membrane and tethering of loops of the small intestine resulting in intestinal obstruction. It is very rare in children. We present a case of a 16-year-old adolescent boy who developed EPS seven years after being placed on continuous ambulatory peritoneal dialysis (CAPD) complicated by several episodes of bacterial peritonitis. The diagnosis was based on clinical, radiological, intraoperative and histopathological findings. The patient was successfully treated with surgical enterolysis. During a 7-year follow-up, there have been no further episodes of small bowel obstruction documented. He still continues to be on regular hemodialysis and is awaiting a deceased donor kidney transplant. EPS is a long-term complication of peritoneal dialysis and is typically seen in adults. Rare cases may be seen in the pediatric population and require an appropriate surgical approach that is effective and lifesaving for these patients.

2571 Unicentric Castleman Disease as a Cause of Ileal Perforation: A Case Report

INTRODUCTION: Castleman disease is describes a group of heterogenous lymphoproliferative disorders that share histopathologic features. It is divided into Unicentric castleman disease (UCD) and Multicentric Castleman disease. We present a case of a patient with one year history of recurrent small bowel obstruction (SBO), which was found to be due to UCD affecting the mesentery. CASE DESCRIPTION/METHODS: A 75 years old gentleman initially presented one year ago with an episode of SBO. He had no history of abdominal or pelvic surgery. CT scan showed a transition point near the terminal ileum and mesenteric/retroperitoneal lymphadenopathy. Patient underwent a colonoscopy which showed a stenotic ileocecal valve with active colitis in the terminal ileum and ascending colon suggestive of resolving intestinal ischemia. This time, patient was admitted with decreased oral intake due to SBO. He was found to have a low albumin of 0.8 and an AKI on CKD. He also had bilateral pleural effusions and new ascites. He was treated conservatively initially, but he developed new abdominal pain with X ray showing free air under the diaphragm concerning for intestinal perforation. Patient underwent emergent laparotomy, where he had a perforated terminal ileum and multiple large fibrotic lymph nodes in the associated mesentery. Pathology showed proliferation of atretic follicles. There were occasional penetrating capillaries and the mantle lymphocytes have an onion-skin pattern. The interfollicular zones showed increased plasma cells, but not prominent vascular proliferation. CD3 and CD20 stains showed an intact immune-architecture. The overall findings showed a mixed pattern of Castleman lymphadenopathy, with some features of both the hyaline vascular and plasma cell variants. He had IgA of 510 mg/dl and an abnormal SPEP with IgG lambda paraprotein of 0.39 g/dl. His hospital course was complicated by septic shock due to bacterial and fungal peritonitis. Patient eventually went into cardiac arrest and died. DISCUSSION: Mixed variant CD is mostly multicentric, however, some patients with UCD reveal features of both hyaline vascular type and plasma cell type. In this case, apart from abdominal pain and recurrent SBO episodes, there were no other complaints. Acute phase reactants, CBC, and serological testing for HIV, HHV-8, Hepatitis B, Hepatitis C, RPR and PPD were all unremarkable. UCD is usually asymptomatic and generally curable using surgical resection but in this case led to severe complication ending in patient's demise.

Do You Eat Healthy? You May Need a Diet Coke! A Case Report of Successful Non-Surgical Phytobezoar Treatment

Cola drinks have become increasingly targeted as dangerous beverages that only increase the risk of diabetes, heart disease, and obesity. However, for certain types of abdominal pain caused by gastric phytobezoars, it is exactly the therapy we need. Phytobezoars are composed of accumulated vegetable material, but there are bezoars composed of hair and medications as well. Risk factors include gastric dysmotility due to previous vagotomy or pyloroplasty, use of opiates and anticholinergics, or prior gastric outlet obstruction. While most remain asymptomatic, they can cause complications such as abdominal pain, obstruction, and anorexia. Surgery can provide definitive treatment for severe cases, however we present an instance where chemical dissolution proved to be a successful alternative. A 62 year old male with a history of Billroth-II bypass surgery 25 years ago and multiple episodes of small bowel obstruction presented with severe left upper quadrant abdominal pain, vomiting, and nausea after eating pizza an hour earlier. An abdominal CT revealed copious amounts of material in a severely dilated stomach. Afterwards, an EGD showed 50% of the stomach obscured by a large gastric bezoar which was unable to be suctioned or passed via endoscopic water jet. The patient was treated with 500 cc of diet cola via gastric lavage BID for seven days for bezoar dissolution. Afterwards, the patient's symptoms resolved and he was discharged after tolerating a full diet without complications.Therapy for bezoars vary depending on their composition, and interestingly for phytobezoars the high sodium bicarbonate content in cola drinks is believed to create carbon dioxide bubbles that dissolve gastric contents. Dosages may vary from 500 cc to 3 L per day for several weeks with or without a combination of other prokinetic agents. Other options include cellulase tablets, papain meat tenderizer, or acetylcysteine via nasogastric tube. To prevent recurrence, patients should be advised to avoid high fiber diets, chew their food carefully, and stay well hydrated. This case represents an important reminder that clinicians should expand their differentials to include gastric bezoars when evaluating for possible causes of acute upper abdominal pain, especially in patients with prior gastric surgery. Although unusual, the existence of cola drinks as a cost-effective and available therapy should be stressed to clinicians to prevent unnecessary endoscopic or surgical treatment.2706_A Figure 1. CT Abdomen showing faecalized gastric contents causing severe gastric dilatation2706_B Figure 2. Large Bezoar occupying 50% of the stomach pouch

Bile duct injuries during laparoscopic cholecystectomy. Long term results. a monoinstitutional experience

Introduction: Bile duct injury(BDI) is perhaps the most feared complication of laparoscopic cholecystectomy(LC).Proper management of BDI is mandatory to avoid immediate or later life -threatening sequelae. Methods: We analyzed our prospectively established bile duct injury(BDI) after laparoscopic cholecystectomy(LC) database. From 1996 to 2017 we treated 47 patients with BDI after LC. The BDIs were graded according to the classification of Strasberg. After treatment the follow-up evaluation was focused on clinical outcome and biochemical analysis. Results: Ten patients had minor BDIs(6 patients had Type A injury and 4 patients had Type D injury). In all of these cases the BDI was recognized postoperatively. Three patients were managed with stents, six patients required laparotomy and bile duct ligation, and one patient underwent laparoscopy and ligation of a duct of Luschka. Thirty seven patients had major bile duct injuries. Three had E1, 9 had E2, 12 had E3, 12 had E4, and 1 patient had type E5 injury. Seven patients had biliary peritonitis lasting from 1 to 6 days, one of them died 20 days postoperatively because of sepsis. Among the patients with a major BDI, a Roux -en-Y hepaticojejunostomy was performed. No postoperative complications have been observed in 43 patients. One patient had four episodes of small bowel obstruction due to adhesions. The final outcome has been graded as excellent in 43 patients and good in 3. Conclusion: Laparoscopic BDI has a significant morbidity and considerable mortality rate. Early recognition and proper management of the patients diminishes the consequences.

Sclerosing encapsulating peritonitis as a potential complication of cytoreductive surgery and HIPEC: Clinical features and results of treatment in 4 patients

Sclerosing encapsulating peritonitis (SEP) is a rare entity characterized by encapsulation of the small bowel and/or the colon by a fibrous tissue that forms a shell. Intraperitoneal chemotherapy (IPC) has been reported to be a potential causative factor of secondary SEP. However, few studies have reported on secondary SEP related to cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Here, we review results from four clinical cases of SEP associated with CRS and HIPEC. In all four patients, additional surgery was necessary to alleviate recurrent episodes of small bowel obstruction. These obstructions can occur as early as several weeks after CRS plus HIPEC or as late as 3 years after treatment. Of utmost importance is the prevention of fistulization which can result in enteric contamination of the peritoneal space. To date, no solution to SEP has been identified except additional surgery but it is evident that these reoperative experiences are difficult for both surgeon and patient. The etiopathogenesis of SEP in this setting remains unknown but it is clear that it is related to chronic inflammation of the peritoneum. Large studies are needed to identify the incidence and potential common causes of SEP after CRS and HIPEC.

Postoperative Small Bowel Obstruction Following Laparoscopic or Open Fundoplication in Children: A Retrospective Analysis Using a Nationwide Database.

Postoperative small bowel obstruction (SBO) is one of the most serious adverse events resulting in deteriorated quality of life in children. Numerous studies have shown that laparoscopic surgery significantly reduces the occurrence of SBO compared with open surgery in adults. However, evidence of the advantages of laparoscopic surgery over open surgery in terms of reducing SBO is lacking in children. Fundoplication is a common abdominal procedure in children. This study was performed to compare the occurrence of SBO after laparoscopic fundoplication (LF) versus open fundoplication (OF). Using the Diagnosis Procedure Combination database, a national inpatient database in Japan, we retrospectively identified patients aged 0-18years who underwent LF or OF from July 2010 to March 2016. Propensity score adjustment was used to compare the occurrence of SBO between the groups. We identified 1838 eligible patients who underwent LF (n = 1362) or OF (n = 476). The median age at surgery was 4.0 and 1.5years in the LF and OF group, respectively (P < 0.001). The median weight at admission was 11.4 and 7.5kg, respectively (P < 0.001). Nineteen (1.4%) patients in the LF group and 13 (2.7%) in the OF group had at least one episode of SBO (P = 0.11, log-rank test). In the propensity score-adjusted Cox regression analysis, SBO was significantly less likely to occur in the LF than OF group (hazard ratio, 0.36; 95% confidence interval 0.16-0.82; P = 0.01). In this retrospective nationwide study, LF was significantly associated with a reduction in SBO compared with OF in children.

Surgery for constipation: systematic review and practice recommendations: Results I: Colonic resection.

To assess the outcomes of colectomy in adults with chronic constipation (CC). Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements (SES) with a summative Oxford Centre for Evidence-Based Medicine (2009) level. Forty articles were identified, providing data on outcomes in 2045 patients. Evidence was derived almost exclusively from observational studies, the majority of which concerned colectomy and ileorectal anastomosis (CIRA) rather than other procedural variations. Average length of stay (LOS) ranged between 7-15days. Although inconsistent, laparoscopic surgery may be associated with longer mean operating times (210 vs 167min) and modest decreases in LOS (10-8days). Complications occurred in approximately 24% of patients. Six (0.4%) procedure-related deaths were observed. Recurrent episodes of small bowel obstruction occurred in about 15% (95%CI: 10-21%) of patients in the long-term, with significant burden of re-hospitalisation and frequent recourse to surgery. Most patients reported a satisfactory or good outcome after colectomy but negative long-term functional outcomes persist in a minority of patients. The influence of resection extent, anastomotic configuration and method of access on complication rates remains uncertain. Available evidence weakly supports selection of patients with an isolated slow-transit phenotype. Colectomy for CC may benefit some patients but at the cost of substantial short- and long-term morbidity. Current evidence is insufficient to guide patient or procedural selection.

Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study

Background and aimsThe use of intrathecal morphine therapy has been increasing. Intrathecal morphine therapy is deemed the last resort for patients with intractable chronic non-cancer pain (CNCP) who failed other treatments including surgery and pharmaceutical interventions. However, effective treatments for patients with CNCP who “failed” this last resort because of severe side effects and lack of optimal pain control remain unclear. Methods and resultsHere we report two successfully managed patients (Ms. S and Mr. T) who had intractable pain and significant complications years after the start of intrathecal morphine therapy. The two patients had intrathecal morphine pump implantation due to chronic consistent pain and multiple failed surgical operations in the spine. Years after morphine pump implantation, both patients had significant chronic pain and compromised function for activities of daily living. Additionally, Ms. S also had four episodes of small bowel obstruction while Mr. T was diagnosed with end stage severe “dementia”. The successful management of these two patients included the simultaneous multidisciplinary approach for pain management, opioids tapering and discontinuation. ConclusionThe case study indicates that for patients who fail to respond to intrathecal morphine pump therapy due to side effects and lack of optimal pain control, the simultaneous multidisciplinary pain management approach and opioids tapering seem appropriate.

Nonoperative management of adhesive small bowel obstruction: what is the break point?

BackgroundThe current management paradigm for recurrent adhesive small bowel obstruction (SBO) is nonoperative. Rates of recurrence differ based on time interval between and number of previous occurrences. Optimal time to intervene has not been determined. MethodsWe constructed a Markov model to evaluate costs and quality of life on a hypothetical cohort of 40-year-old patients after their first episode of medical management for postoperative SBO. We estimated a relative risk reduction of .55 with surgical intervention and a relative risk increase of 2.1, 2.9, and 5.7 after the medical management of the 2nd, 3rd, and 4th SBO. ResultsSurgery performed after earlier episodes of SBO was more costly but also more effective. The cost difference between surgery after the 1st SBO recurrence vs the 2nd SBO recurrence was $1,643, with an increase of .135 quality-adjusted life years (QALYs), the incremental cost-effectiveness ratio was $12,170 per QALY. ConclusionsSurgery after the first episode of SBO provides a small increase in QALY at a small cost since surgical intervention lowers the risk of recurrence.

Disseminated Gastrointestinal Histoplasmosis Resulting in Benign Ileal Stricture in a Patient with Hyperimmunoglobulin M Syndrome

Gastrointestinal histoplasmosis (GIH) is common in patients with disseminated disease affecting both immunocompetent and immunocompromised patients. However, it is often unrecognized due to a lack of specific signs and symptoms. It has only rarely been reported to cause small bowel obstruction (SBO), and the majority of reported cases were in patients with AIDS. We describe a case of GIH presenting with ileal stricture in a patient with hyperimmunoglobulin M (IgM) syndrome. A 37-year-old male with a past medical history of congenital hyper-IgM syndrome treated with regular immune globulin infusions and recently diagnosed disseminated histoplasmosis confirmed by laparoscopic mesenteric lymph node biopsy. The patient was status post a two week course of amphotericin B switched to maintenance itraconazole following undetectable urine histoplasma antigen level and significant clinical improvement. Shortly after initial completion of therapy, the patient had suffered a complicated course with three admissions over the course of two weeks with abdominal pain and CT confirmed SBO with each episode treated conservatively. Upon the patient's fourth presentation, gastroenterology was consulted for further investigation. CT enterography demonstrated 6 cm nodular thickening across the terminal ileum and a tight ileal stenosis. Additionally, a urine histoplasma antigen was elevated. Colonoscopy with ileoscopy confirmed stenosis and dilation was achieved with CRE balloon dilator. Biopsy of the stricture showed active ileitis without granulomas. Given his previous history of disseminated histoplasmosis associated with imaging and laboratory abnormalities, GIH was highly suspected. The patient elected to continue itraconazole rather than amphotericin B due to its side effect profile. Urine histoplasma antigen level was undetectable at 1-month follow-up and no further SBO episodes occurred. GIH is usually characterized by segmental inflammation and ulceration of the GI tract. However, these findings may be incorrectly attributed to malignancy and inflammatory bowel disease leading to the inappropriate use of immunosuppressive medications. This case demonstrates the diagnostic value of CT enterography and urine histoplasma antigen in GIH when pathology results are non-diagnostic as well as the effectiveness of endoscopic therapy. It also highlights the unusual occurrence of a short segment of stricture as the result of an otherwise disseminated process.Figure 1Figure 2

Sclerosing Encapsulating Peritonitis: Review.

Sclerosing encapsulating peritonitis (SEP) is a rare chronic inflammatory condition of the peritoneum with an unknown aetiology. Also known as abdominal cocoon, the condition occurs when loops of the bowel are encased within the peritoneal cavity by a membrane, leading to intestinal obstruction. Due to its rarity and non-specific clinical features, it is often misdiagnosed. The condition presents with recurrent episodes of small bowel obstruction and can be idiopathic or secondary; the latter is associated with predisposing factors such as peritoneal dialysis or abdominal tuberculosis. In the early stages, patients can be managed conservatively; however, surgical intervention is necessary for those with advanced stage intestinal obstruction. A literature review revealed 118 cases of SEP; the mean age of these patients was 39 years and 68.0% were male. The predominant presentation was abdominal pain (72.0%), distension (44.9%) or a mass (30.5%). Almost all of the patients underwent surgical excision (99.2%) without postoperative complications (88.1%).

Assessment of Bowel Wall Enhancement for the Diagnosis of Intestinal Ischemia in Patients with Small Bowel Obstruction: Value of Adding Unenhanced CT to Contrast-enhanced CT.

Purpose To determine whether adding unenhanced computed tomography (CT) to contrast material-enhanced CT improves the diagnostic performance of decreased bowel wall enhancement as a sign of ischemia complicating mechanical small bowel obstruction (SBO). Materials and Methods This retrospective study was approved by the institutional review board, which waived the requirement for informed consent. Two gastrointestinal radiologists independently performed retrospective assessments of 164 unenhanced and contrast-enhanced CT studies from 158 consecutive patients (mean age, 71.2 years) with mechanical SBO. The reference standard was the intraoperative and/or histologic diagnosis (in 80 cases) or results from clinical follow-up in patients who did not undergo surgery (84 cases). Decreased bowel wall enhancement was evaluated with contrast-enhanced images then and both unenhanced and contrast-enhanced images 1 month later. Diagnostic performance of decreased bowel wall enhancement and confidence in the diagnosis were compared between the two readings by using McNemar and Wilcoxon signed rank tests. Interobserver agreement was assessed by using κ statistics and compared with bootstrapping. Results Ischemia was diagnosed in 41 of 164 (25%) episodes of SBO. For both observers, adding unenhanced images improved decreased bowel wall enhancement sensitivity (observer 1: 46.3% [19 of 41] vs 65.8% [27 of 41], P = .02; observer 2: 56.1% [23 of 41] vs 63.4% [26 of 41], P = .45), Youden index (from 0.41 to 0.58 for observer 1 and from 0.42 to 0.61 for observer 2), and confidence score (P < .001 for both). Specificity significantly increased for observer 2 (84.5% [104 of 123] vs 94.3% [116 of 123], P = .002), and interobserver agreement significantly increased, from moderate (κ = 0.48) to excellent (κ = 0.89; P < .0001). Conclusion Adding unenhanced CT to contrast-enhanced CT improved the sensitivity, diagnostic confidence, and interobserver agreement of the diagnosis of ischemia, a complication of mechanical SBO, on the basis of decreased bowel wall enhancement. (©) RSNA, 2016.

Isolated Enteric Mastocytosis Causing Recurrent Small Bowel Obstruction

Mast cells are involved in many allergenic and non-allergenic inflammatory events in the gastrointestinal (GI) tract. Local proliferation of mast cells can lead to alteration of GI function and systemic symptoms. GI symptoms may include abdominal pain, nausea, vomiting and diarrhea. We report a rare case of isolated mastocytosis of the small bowel causing recurrent small bowel obstruction (SBO). Case Presentation: A 37-year-old male with no significant past medical or surgical history was referred to our center for evaluation of recurrent SBO of unclear etiology. His usual “attacks” presented with abdominal pain and CT scans of abdomen intermittently concerning for a possible small bowel stricture, terminal ileum thickening with upstream dilation of the small bowel. His symptoms would resolve with conservative management. He had no known drug or seasonal allergies. Extensive laboratory and endoscopic evaluations were non-diagnostic and he continued to have 1-2 such episodes per month with no precipitating factors. After 2 years of these “attacks” he was hospitalized again with another episode of SBO. He underwent a proximal ileal segmental resection and primary anastomosis. Pathology revealed significant mast cells infiltration of the small bowel, up to 20/hpf. These results were thought to be suspicious for mastocytic enteritis. His PPI therapy was switched to an H2 blocker to prevent histamine release. The patient has remained symptom free since then for the last 9 months with no further attacks of SBO. Discussion: Mast cells play an important role in the regulation of gastrointestinal visceral sensitivity and vascular permeability. Increased number of mast cells can be seen in the mucosa of patients with inflammatory bowel disease, irritable bowel syndrome, mastocytic enterocolitis, systemic mastocytosis and parasitic infections. Features of mastocytosis in GI biopsies are not well described and difficult to diagnose. In our case, the presentation was very rare with only isolated mastocytosis of the GI tract causing recurrent SBO. Management is aimed at stabilizing mast cells and controlling mediator release with antihistamines and antileukotrienes to prevent symptoms. Conclusion: We present a rare case of recurrent SBO caused by isolated small intestinal mastocytosis without any systemic mastocytosis. This entity should be in the differential diagnosis for potentially rare causes of unexplained, recurrent SBO.

Laparoscopy for small bowel obstruction in children--an update.

We evaluated the current role of minimally invasive surgery (MIS) in children with small bowel obstruction (SBO) at our institution. A retrospective review of patients undergoing MIS for acute SBO was performed from 2008 to 2013. The study population was compared with a historical control including patients from 2001 to 2008. There were 71 patients who met inclusion criteria; 35 were male, and 36 were female. Sixty-two children underwent laparoscopy for their first episode of SBO, and 12 underwent laparoscopy for recurrent SBO, accounting for 74 episodes of SBO managed with MIS. The most common etiology of SBO was adhesions (n=40). Laparoscopy and laparoscopic-assisted procedures were associated with shorter nasogastric tube decompression (1.4±2 days [P<.001] and 1.5±2.7 days [P=.002], respectively) and time to regular diet (3.9±4 days [P=.002] and 4.6±2.8 days [P=.024], respectively) compared with those converted to laparotomy (5.1±4.9 days of nasogastric tube decompressions and 8±4.7 days to regular diet). There was no difference in postoperative morbidity comparing laparoscopy (11%), laparoscopic-assisted (5%), and laparoscopic converted to open procedures (18%) (P=.48). Laparoscopy continues to be a safe diagnostic and therapeutic tool in the management of pediatric SBO.

Endoscopic Removal of Gallstone Through Choledochoduodenal Fistula

Introduction: We present a 91-year-old female presenting with abdominal pain and found to have a large gallstone and choledochoduodenal fistula successfully treated with endoscopy. She presented with a 1-week history of nonspecific abdominal pain, bloating, constipation, and nonbilious vomiting. Two weeks prior to her admission, she had an episode of small bowel obstruction from gallstone treated by exploratory laparotomy with stone removal from terminal ileum. On examination she was afebrile and anicteric. Abdomen was soft, nontender with hypoactive bowel sounds. Right upper quadrant ultrasound revealed a large 3.7-cm stone in the gallbladder fundus and possible cholecystoduodenal fistula. Upper endoscopy showed a cholecystoduodenal fistula in the duodenal bulb and a large impacted stone (Figure 1) in the gallbladder fundus. Subsequently, the gallstone was disimpacted from gallbladder fundus (Figure 2) using multiple endoscopic accessories. Roth net was used to remove the intact stone per orum. There was mild gallbladder mucosal edema without any stone remnants (Figure 3) at the conclusion of the procedure. Her symptoms improved after the endoscopy and she was discharged home 2 days later. Bouveret syndrome refers to a gastric outlet obstruction secondary to impaction of a gallstone in the pylorus or proximal duodenum.Figure 1Figure 2Figure 3

Small bowel obstruction in patients with familial adenomatous polyposis related desmoid disease

Intra-abdominal desmoid disease is one of the most common extra-intestinal manifestations of familial adenomatous polyposis. Small bowel obstruction occurs frequently in affected patients and is notoriously difficult to treat. The aim of this study was to review the management and outcome of desmoid-related small bowel obstruction. This was a retrospective, descriptive study of patients with familial adenomatous polyposis and intra-abdominal desmoid disease who developed small bowel obstruction. Demographic data and data concerning the presentation, diagnosis and treatment of the bowel obstructions were abstracted from the polyposis database or patients' records. Patients with obstruction unrelated to desmoid disease were excluded. There were 47 patients (30 women and 17 men). Median age at first bowel obstruction was 24.2 (interquartile range 19.2-34.2) years. The median time from index surgery to first bowel obstruction was 4.1 (interquartile range 1.5-9.0) years. Twenty-two patients had a colectomy and ileorectal anastomosis and 21 a proctocolectomy and ileoanal pouch. Obstruction was treated medically in 29% of cases and surgically in 69%. Thirteen patients had total parental nutrition. Thirty (63.8%) had a second episode of small bowel obstruction at a mean of 5.3 years after the first, 50% of which were treated medically. Eighteen (37.5%) patients had more than two episodes of bowel obstruction. There were 118 operations, including lysis of adhesions (29), small bowel resection (14), bypass (12), ileostomy (12), desmoid excision (9) and stricturoplasty (2). Desmoid-related small bowel obstruction in familial adenomatous polyposis patients requires multiple surgical strategies to restore a patent gastrointestinal tract. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: This is the only series in the literature specifically addressing small bowel obstruction in patients with familial adenomatous polyposis and intra-abdominal desmoid disease. The data show that small bowel obstruction is common, tends to recur, but can be successfully managed by a combination of medical and well selected surgical treatment.

Complications and functional outcomes of restorative proctocolectomy for ulcerative colitis in the elderly

BackgroundRestorative proctocolectomy with ileopouch-anal anastomosis (IPAA) is the treatment of choice for intractable or complicated ulcerative colitis (UC). Debate exists concerning outcomes of IPAA in the elderly and literature data are scarce. We report our experience of IPAA in older population.MethodsWe gathered data on a prospective database of patients undergoing IPAA for UC over 70 years of age in our Unit from January 1990 through January 2010. Patients were compared with randomly selected younger controls on a 1:3 ratio. Patients underwent IPAA in 2 or 3 stages. Demographical data, disease characteristics, comorbidities, concomitant medications, peri-operative management, intra- and post-operative complications were analyzed. Function and quality of life were assessed by clinical visit and Inflammatory Bowel Disease Questionnaire 1 and 3 years after ileostomy takedown.ResultsTwenty-seven elderly patients underwent IPAA for UC in the study period; these were compared with 81 younger controls. The former had more comorbidities and higher ASA score. All patients underwent loop-ileostomy closure. There were no differences between groups concerning the rate of major complications, but elderly patients more frequently had nuisances due to stoma output. Younger patients experienced significantly more episodes of small bowel obstruction. No significant differences in bowel control and health-related quality of life was observed, except for an higher rate of elderly patients taking antidiarrhoeals at 1-year follow-up; this observation was not confirmed at 3-year follow-up. A minimal decrease in continence was observed, but this did not affect overall satisfaction.ConclusionsIPAA can be safely offered to selected elderly UC patients who are strongly motivated and with no clinical disturbances of continence. In experienced hands no differences are likely to be expected concerning complications, quality of life and function. Results are stable with time and comparable to those of younger patients.