Management Of Bowel Obstruction Research Articles

Rethinking adhesional small bowel obstruction management: the case for dexamethasone as a non-operative alternative.

Rethinking adhesional small bowel obstruction management: the case for dexamethasone as a non-operative alternative.

FP7.7 - Evaluation of small bowel obstruction management: A local audit in comparison to NASBO guidelines

Abstract Aims The National Audit of Small Bowel Obstruction (NASBO) report provides recommendations for optimising the management of small bowel obstruction (SBO). We aimed to audit our management and compare our outcomes with the NASBO report. Methods Retrospective case reviews were conducted for 115 patients admitted with SBO from July-December 2022, evaluating adherence to NASBO guidelines and assessing outcomes. Results The average age was 76 (21-94) years old; 53% male and 47% female. Adhesions (41.7%), hernias (30.4%), malignancy (13%) and inflammatory bowel disease (6.1%) were predominant causes. Treatment included conservative management in 67% of cases, surgery in 27% (of which, 6.1% had a trial of conservative management initially) and palliative care in 6.1%. A summary of the management and outcomes below.Table 1:Summary of managementCT scan on admissionAverage time to CTSurgery performedAverage time to surgeryNutritional screening assessmentLocal audit98.3%9 hours27%2.4 days100%NASBO80%2.2 days48%1 day90%Table 2:Summary of outcomesUnable to eat normally for ≥5 daysAverage length of stay30-day mortality30-day readmissionLocal audit12%7 days14%18%NASBO49%10.7 days8%13% Conclusion We are performing CT scans in a timely manner and screening for malnutrition. Despite a shorter length of stay compared to NASBO, our audit has identified opportunities to improve hospital readmission, suggesting that we may be discharging patients prematurely. We have introduced a SBO checklist to ensure NASBO recommendations are adhered to and to improve our 30-day outcomes.

215 Title: An Overview of Adhesional Small Bowel Obstruction Management Across Two High-Volume Tertiary Centres in the North West of England

215 Title: An Overview of Adhesional Small Bowel Obstruction Management Across Two High-Volume Tertiary Centres in the North West of England

1071 Evaluation of Adhesive Small Bowel Obstruction Management: Insights from a Retrospective Analysis

1071 Evaluation of Adhesive Small Bowel Obstruction Management: Insights from a Retrospective Analysis

Hydrocolpos causing bowel obstruction in a preterm newborn: a case report

BackgroundImperforate hymen is the most common congenital defect of the female urogenital tract. The spectrum of clinical manifestations is broad, ranging from mild cases undiagnosed until adolescence to severe cases of giant intraabdominal masses. The most common complication of hydrocolpos is bladder compression, resulting in obstructive uropathy and hydronephrosis.Case presentationWe present here the case of a preterm neonate who was admitted to the surgical neonatal intensive care unit for bowel obstruction. The baby did not appear septic or unwell, a small amount of meconium passed frequently, and no bilious gastric residuals occurred. Based on these findings, acute abdominal obstruction was doubtful, and the surgeon chose a conservative (watch and wait) approach. Subsequently, we performed abdominal ultrasound and magnetic resonance imaging based on unclear information about a suspicious abdominal mass raised by the gynecologist shortly before the emergency C-section. The final diagnosis was congenital hydrocolpos due to imperforate hymen. The pediatric gynecologist indicated an incision of the imperforate hymen under general anesthesia. The incision resolved abdominal distention as well as the bowel obstruction.ConclusionThe presentation of hydrocolpos was not typical (no bulging in the vaginal introitus) in our case, and clinical symptoms implied acute bowel obstruction shortly after birth. The surgeon chose a conservative (watch and wait) approach as the baby did not appear unwell on the second day of life. Fortunately, diagnostic laparotomy was not required as the next step in bowel obstruction management. All clinical symptoms resolved after a minor surgical procedure.

Surgical management of small bowel obstruction: What you need to know.

Abstract Small bowel obstruction management has undergone a paradigm shift over the past decade. Surgical dictum had taught us to never let the “sun rise or set on a small bowel obstruction.” We have subsequently learned that a nuanced approach to this disease using practice management guidelines to drive our clinical decision making must be taken. In this review, we will delve into the process of deciding who needs an urgent/emergent operation versus observing a patient on the ward. We will also discuss how long to wait until an exploration should be performed for those patients initially undergoing non-operative management, and, once in the operating room, the fundamental techniques and newer approaches which should be in surgeon’s armamentarium. Lastly, we will highlight the approach to less common causes of small bowel obstruction including malignant bowel obstruction, virgin abdomens, and Crohn’s disease.

Arterial-colonic fistula secondary to colonic stent erosion into the left external iliac artery

Self-expandable metal stent (SEMS) are widely utilized as a bridge to surgical intervention and for palliative treatment of malignant bowel obstructions. The risk of complications associated with SEMS is low in well-selected patients. Stent erosion is a rare but serious adverse event that is associated with high morbidity and mortality. Here, we report the case of a 74-year-old patient with a colonic obstruction secondary to a pelvic mass that was treated with SEMS and radiotherapy, who developed a partial thickness stent erosion and recurrent hematochezia 6years after placement. Endoscopic retrieval was not technically feasible. During attempted surgical resection, massive hemorrhage occurred from a colonic-arterial fistula to the left external iliac artery resulting in death. While SEMS remain an effective, minimally invasive approach for the management of bowel obstructions, prolonged in-situ lifetime may confer an increased risk of serious adverse events including erosion and fistula formation.

EGS P31 A Rare Case of Jejunal Obstruction Secondary to Necrotic Peripancreatic Abscess (CASE REPORT)

Abstract Background Acute pancreatitis is one of the major causes for emergency hospital admissions worldwide. Bowel obstruction following acute pancreatitis usually occur as a result of retroperitoneal inflammation and mesenteric infiltration in the inflammation; especially at duodenum, transverse colon and splenic flexure due to the proximity to pancreas. We hereby, present a rare case of jejunal obstruction secondary to sterile necrotic peripancreatic abscess. Through this case report, we aim to emphasize increased awareness required among general surgeons and the need for appropriate clinical judgement in the management of bowel obstruction - medical versus surgical intervention. Methods Case Report: A 65-year-old lady presented in emergency with an acute 10-hour history of epigastric pain with nausea. She drank no alcohol, was otherwise well and had no other significant co-morbidities. On examination, she was tender in the epigastrium with no signs of peritonitis. She had raised serum amylase diagnostic of acute pancreatitis. All other blood investigations and an ultrasound abdomen was unremarkable. The cause of pancreatitis was unclear. She was admitted and treated in a conventional fashion. Over next 2 days, the patient's C-reactive protein increased and she became hypotensive warranting HDU care. Computed Tomography of abdomen and pelvis (CTAP) confirmed acute pancreatitis with no associated complications. She made slow progress. A Nasojejunal tube was inserted for nutritional support. Over the next five days, she had abdominal distention with absolute constipation and was treated for ileus. Further CT imaging suggested partial small bowel obstruction. Clinical condition failed to progress despite 48 hours of conservative management and decision was taken for a diagnostic laparoscopy. Results Intra-operatively, multiple small bowel loops were found densely adherent to the inferior border of pancreas, each with a clear evidence of upstream bowel dilatation. The cause was a peripancreatic necrotic abscess cavity. Laparoscopic division of adhesions allowed access to the cavity. A washout was performed and a drain inserted. Post-operatively, she had an uneventful recovery. She was gradually built on enteral nutrition and her bowels started working normally. She was discharged on post-op day 5 and drain removed as an outpatient. She had no complications at 60-day follow-up. Conclusions Bowel complications of acute pancreatitis (paralytic ileus, mechanical obstruction, bowel ischaemia and perforation) are relatively infrequent, with few cases reported in literature. Prediction of disease severeity is crucial to guide the treatment plan. In majority of cases, abdominal distention and absolute constipation is usually ileus and managed conservatively. Care should be taken in unsettling patients and diagnostic laparoscopy should be undertaken to evaluate the cause and manage accordingly.

ASO Author Reflections: Challenges in the Management of Bowel Obstruction after Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy.

ASO Author Reflections: Challenges in the Management of Bowel Obstruction after Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy.

Prompt intervention in large bowel obstruction management: A Nationwide Inpatient Sample analysis

BackgroundLarge bowel obstruction is an urgent condition which can progress to ischemia and perforation. The importance of prompt intervention has not been rigorously demonstrated. MethodsPatients with bowel obstruction who underwent stoma, stent, and/or colectomy in the Nationwide Inpatient Sample were used to study prompt intervention (defined as occurring within 2 days of admission). Outcomes were inpatient mortality, discharge to home, and length of stay in an adjusted analysis. ResultsAmong the 31,277 patients, prompt intervention occurred in 42.6%. In an adjusted analysis, prompt intervention was more likely in higher income patients and less likely in patients with comorbidities; among those with malignant obstruction, less likely in women, and among those with benign obstruction, less likely in Blacks. Inpatient mortality (6%) was not different between groups. Discharge home (71% vs 68%; p < 0.0001) and shorter LOS (−3 days) occurred in those managed promptly. ConclusionPrompt intervention in large bowel obstruction results in decreased LOS and greater likelihood of discharge to home, but not a mortality benefit. Female, Black and lower income patients were less likely to have prompt intervention.

Brazilian Society of Surgical Oncology guidelines for malignant bowel obstruction management.

Malignant bowel obstruction (MBO) is a frequent complication in advanced cancer patients and especially those with abdominal tumors. The clinical management of MBO requires a specific and individualized approach based on the disease prognosis. Surgery is recommended. Less invasive approaches such as endoscopic treatments should be considered when surgery is contraindicated. The priority of care for inoperable and consolidated MBO is to control the symptoms and promote the maximum level of comfort. This study aimed to develop recommendations for the effective management of MBO. A questionnaire was administered to all members of the Brazilian Society of Surgical Oncology, of whom 41 surgeons participated in the survey. A literature review of studies retrieved from the National Library of Medicine database was conducted on particular topics chosen by the participants. These topics addressed questions regarding the MBO management, to define the level of evidence and strength of each recommendation, and an adapted version of the Infectious Diseases Society of America Health Service rating system was used. Most aspects of the medical approach and management strategies reviewed were strongly recommended by the participants. Guidelines outlining the strategies for management MBO were developed based on the strongest evidence available in the literature.

Bowel obstruction following pediatric abdominal cancer surgery

Pediatric bowel obstruction after intra-abdominal cancer surgery is relatively frequent. Few publications have specifically addressed this significant complication. The purpose of this study was to assess the frequency, etiology and treatment options of bowel obstructions following abdominal cancer surgery in children using our institutional database. We retrospectively analyzed a single tertiary pediatric hospital database over a 10-year period. The clinical characteristics of patients with and without bowel obstruction were compared using bivariate analyses. The details of the conservative and operative management of bowel obstructions were evaluated. Out of 130 eligible patients, 18 (13.8%) developed bowel obstruction in a mean follow-up of 5.7years. Patients who developed bowel obstruction were more likely to have received preoperative radiation therapy (16.7 vs 2.7%, p = 0.036) and had longer operative time (398 vs 268min, p = 0.022). Non-operative management was successful in 39% of patients (7/18). When patients needed surgical intervention, minimally invasive approach was attempted and successfully performed in 36% of cases (4/11), none of which required conversion to laparotomy nor presented with recurrent bowel obstruction. Bowel obstruction is a frequent complication after abdominal cancer surgery in children. Conservative management is frequently successful. For patients requiring surgical treatment, laparoscopy remains a valuable option and should be considered in selected cases.

Small bowel obstruction managed without hospital admission: A safe way to reduce both cost and time in the hospital?

BackgroundSmall bowel obstruction management has evolved to incorporate the Gastrografin challenge. We expanded its use to the emergency department observation unit, potentially avoiding hospital admission for highly select small bowel obstruction patients. We hypothesized that the emergency department observation unit small bowel obstruction protocol would reduce admissions, costs, and the total time spent in the hospital without compromising outcomes. MethodsWe reviewed patients who presented with small bowel obstruction from January 2015 to December 2018. Patients deemed to require urgent surgical intervention were admitted directly and excluded. The emergency department observation unit small bowel obstruction guidelines were introduced in November 2016. Patients were divided into pre and postintervention groups based on this date. The postintervention group was further subclassified to examine the emergency department observation unit patients. Cost analysis for each patient was performed looking at number of charges, direct costs, indirect cost, and total costs during their admission. ResultsIn total, 125 patients were included (mean age 69 ± 14.3 years). The preintervention group (n = 62) and postintervention group (n = 63) had no significant difference in demographics. The postintervention group had a 51% (36.7 hours, P < .001) reduction in median duration of stay and a total cost reduction of 49% (P < .001). The emergency department observation unit subgroup (n = 46) median length of stay was 23.6 hours. The readmission rate was 16% preintervention compared to 8% in the postintervention group (P = .18). ConclusionManagement of highly selected small bowel obstruction patients with the emergency department observation unit small bowel obstruction protocol was associated with decreased length of stay and total cost, without an increase in complications, surgical intervention, or readmissions.

EP.FRI.500 Establishing a protocol of management of acute bowel obstruction in a tertiary hospital in the Middle East

Abstract Aim To establish a protocol of management of acute bowel obstruction in a tertiary hospital in the Middle East. Method An online search in PubMed, Cochrane reviews and Google Scholar for the period between 2010 and 2020 was performed to identify all published guidelines and recommendations for the management of acute bowel obstruction including the keywords small/large bowel or intestinal obstruction, adhesive obstruction, complete/ partial obstruction and conservative/ surgical management of bowel obstruction. Results A protocol of management of acute bowel obstruction has been developed, reviewed and approved by different concerned departments in the hospital. The indicators to monitor the implementation of the protocol had been approved by the Quality and Risk Management Committee of the hospital. The protocol is divided into 7 sections. These sections include:1) ER assessment with all essential clinical, laboratory and radiological investigations required going hand in hand with resuscitation, hydration, pain control and antibiotic prophylaxis.2) Surgical assessment by senior trainee who will liaise with consultant surgery on call. 3) Radiological assessment guidelines done by senior Radiologist to review the CT scan. 4) Admission criteria. 5) Risk prediction scorings with involvement of critical care team if indicated. 6) Surgical management guidelines with rapid access to operating theatre if indicated. 7) Non- surgical management guidelines including conservative, radiological and endoscopic management. Conclusion Multidisciplinary team approach is essential for the management of acute bowel obstruction. Hospital agreed guidelines and protocols can reduce the significant morbidity and mortality associated with common clinical conditions hence improving patient’s care.

EP.FRI.82 Using NCEPOD guidelines to develop an evidence based pathway for acute bowel obstruction

Abstract Bowel obstruction is a common presentation and poses a significant challenge for clinicians. This condition is associated with a high level of mortality and morbidity. The aim of this project was to assess the clinical pathway for patients presenting with bowel obstruction and improve the overall care they received. This was achieved using guidance from the 2020 NCEPOD report looking at bowel obstruction management. Best practice guidelines from the NCEPOD report were used to assess aspects of patient care such as the time to senior review, assessment of nutrition/fluid status and risk of mortality/morbidity assessment. This identified areas where the standard of care was good, such as the majority of patients being assessed by a consultant within 14 hours. However, it also identified areas such as hydration and nutritional status assessment, documentation of ceilings of care/treatment escalation plans and calculation of risk of mortality and morbidity, which required improvement. An admission checklist and nutritional scoring sheet was created to help prompt clerking doctors when admitting patients with acute bowel obstruction. All cases of bowel obstruction were then prospectively audited over a 2 month period to assess the impact of these changes. The findings were presented at the departmental meetings to increase clinician awareness. Following the audit period, local guidelines were amended to incorporate the NCEPOD recommendations, specific pathways were also made for adhesive small bowel obstruction and malignant large bowel obstruction due to the specific requirements of these conditions.

Malignant Bowel Obstruction Management Over Time: Are We Doing Anything New? A Current Narrative Review.

Malignant bowel obstruction from peritoneal carcinomatosis affects a significant proportion of luminal gastrointestinal and ovarian oncology patients, and portends poor long-term survival. The management approach for these patients includes a range of medical therapies and surgical options; however, how to select an optimal treatment strategy remains enigmatic. The goal of this narrative review was to summarize the latest evidence around multimodal malignant bowel obstruction treatment and to establish if and where progress has been made. A targeted literature search examining articles focused on the management of malignant bowel obstruction from peritoneal carcinomatosis was performed. Following data extraction, a narrative review approach was selected to describe evidence and guidelines for surgical prognostic factors, imaging, tube decompression, medical management, nutrition, and quality of life. Outcomes in the literature to date are summarized for various malignant bowel obstruction treatment strategies, including surgical and non-surgical approaches, as well as a discussion of the role of total parenteral nutrition and chemotherapy in holistic malignant bowel obstruction management. There has been little change in survival outcomes in malignant bowel obstruction in over more than a decade and there remains a paucity of high-level evidence to direct treatment decision making. Healthcare providers treating patients with malignant bowel obstruction should work to establish consensus guidelines, where feasible, to support medical providers in ensuring compassionate care during this often terminal event for this unique patient group.

Bowel Obstruction After Sacrocolpopexy: A Case Series.

Bowel obstruction after sacrocolpopexy (SC) can cause significant morbidity. The aim of this study was to delineate clinical and surgical factors associated with bowel obstruction after SC and to describe its presentation, management, and sequelae. We performed a retrospective case series of patients who underwent open, laparoscopic, or robotic SC within a large health maintenance organization and a single academic medical center between January 1, 2009, and December 31, 2019. Of 3,231 patients who underwent SC, 32 (1.0%) experienced a bowel obstruction. Sacrocolpopexy was performed laparoscopically or robotically in 19 (59.4%) and abdominally in 13 (40.6%). The mean time to bowel obstruction was 1.9 years (SD, 2.5; range, 3 days to 8.8 years). In patients who experienced bowel obstruction, medical management was undertaken in 19 (61.3%) cases. Eight of the 13 (61.5%) surgically managed cases underwent bowel resection, and 3 cases (23.1%) reported partial mesh excision. Recurrent obstruction was seen in 2 (10.5%) of the medically managed and 2 (15.4%) of the surgically managed cases. Bowel obstruction is a rare complication of SC and our rate of at least 1.0% corroborates those in the literature. Obstruction occurs from days to years after SC. Nonsurgical management was effective in most cases, with low rates of recurrent obstruction. In surgically managed cases, the majority included bowel resection or mesh excision; however, mesh excision was not associated with a subsequent identifiable procedural intervention for recurrent prolapse. These data inform patient counseling and surgical planning before SC and aid in diagnosis and management of bowel obstruction after SC.

Non-Surgical Management of Malignant Bowel Obstruction in Advanced Ovarian Cancer patients: A Systematic Review and Meta-Analysis.

Background:Malignant bowel obstruction is a common cause of morbidity and mortality in patients with advanced ovarian cancer. Many patients aren’t suitable for, or decline, surgical decompression. The outcomes for this frail group of patients are not well characterized.Aim:To evaluate survival outcomes of ovarian cancer patients who undergo non-surgical management of malignant bowel obstruction.Design:Systematic review and meta-analysis.Data Sources:Online literature search of Pubmed, Embase and Medline libraries up until December 2020. Searching abstracts of scientific meetings, reference lists of included studies and contacting experts in the field.Selection Criteria:Studies that investigated non-surgical management of confirmed bowel obstruction in advanced ovarian cancer patients were included. All levels of evidence including RCTs, cohort studies and case-series if they included greater than 5 patients.Data Collection and Analysis:The studies were independently chosen by two reviewers who extracted and analyzed the data separately through OpenMeta Analyst software. Study quality was assessed using the JADAD score and the Newcastle Ottawa Score.Results:24 studies met the eligibility criteria for the systematic review and 9 for the meta-analysis. Median survival of patients managed non-surgically for bowel obstruction was 44 days (95% CI 38-49 days, I 2 = 0%, P = 0.128).Conclusion:The quality of studies was relatively low, however the evidence shows that non-surgical management of bowel obstruction results in a short life expectancy but with controlled symptoms. Where quality of life is the main concern, this may be a feasible and effective strategy.

Endoscopic Management of Bowel Obstruction.

The traditional morbidity and mortality associated with traditional management has stimulated exploration of endoscopic approaches. Success depends on patient selection, the location and etiology of obstruction, patient status, and the capability of the endoscopist. This article discusses techniques of intralumenal dilation and stent placement and results from systematic reviews.

Timing of Gastrografin administration in the management of adhesive small bowel obstruction (ASBO): Does it matter?

BackgroundGastrografin challenge is increasingly used as a diagnostic tool to predict patients who may benefit from nonoperative management in adhesive small bowel obstruction. This study explores the optimal timing of Gastrografin in the management of adhesive small bowel obstruction by comparing early versus late Gastrografin challenge. MethodsA retrospective chart review from January 2016 to January 2018 identified patients with adhesive small bowel obstruction who underwent Gastrografin challenge. A receiver operating characteristic curve, to predict a duration of stay less than 5 days, calculated a 12-hour limit which separated early and late groups. Nonoperative and operative patients were compared separately. Our primary outcome was duration of stay. Secondary outcomes included operative requirement, time to the operating room, complication rate, and 1-year mortality. In a separate analysis, multivariable logistic regression identified independent risk factors for 1-year mortality. ResultsOne hundred thirty-four patients were identified (58 early, 76 late). In nonoperative patients, the early group had a shorter duration of stay (3.2 days vs 5.4 days), fewer complications, and a lower complication and 1-year mortality rate (P < .05). In operative patients, the early group had a shorter preoperative duration of stay (1.8 days vs 3.9 days) (P < .05). On multivariable regression, congestive heart failure, any postoperative complication, and operative requirement were the best predictors of 1-year mortality (R2 = 0.321; P < .05). ConclusionGastrografin administration within 12 hours of adhesive small bowel obstruction diagnosis had favorable outcomes in terms of duration of stay, complications, and mortality in nonoperative patients. Moreover, in operative patients, preoperative duration of stay was shortened. Our findings suggest protocolizing early Gastrografin challenge may be an important principle in adhesive small bowel obstruction management.