Bowel Resection Rate Research Articles

Comparison of endovascular therapy and open surgical revascularization in patients with acute superior mesenteric artery occlusion

Abstract Background Acute mesenteric ischemia (AMI) is rare, and few large-scale trials have evaluated endovascular therapy (EVT) and open surgical revascularisation (OS). This study aimed to assess clinical outcomes after EVT or OS for acute superior mesenteric artery occlusion (SMAO) and identify predictors of mortality and bowel resection. Methods Data from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination database from April 2012 to March 2020 were retrospectively analyzed. Overall, 746 patients with acute SMAO who underwent revascularisation were classified into two groups: EVT (n=475) or OS (n=271). The primary clinical outcome was in-hospital mortality. The secondary outcomes were bowel resection, bleeding complications (transfusion or endoscopic hemostasis), major adverse cardiovascular events (MACEs), hospitalisation duration, and cost. Results The in-hospital death or bowel resection rate was approximately 30%. In-hospital mortality (22.5% vs. 21.4%, p=0.72), bowel resection (8.2% vs. 8.5%, p=0.90), and MACEs (11.6% vs. 9.2%, p=0.32) were comparable between the EVT and OS groups, respectively (Table.1). EVT was advantageous in terms of hospitalisation duration and cost (both p<0.0001). Interaction analyses revealed that EVT and OS had no significant difference in terms of in-hospital death in patients with thromboembolic and atherothrombotic characteristics (Figure.1). Multivariate logistic regression analysis revealed that advanced age, decreased activities of daily living, chronic kidney disease, and old myocardial infarction were significant predictive factors for in-hospital mortality. Diabetes Mellitus was a predictor of bowel resection after revascularisation. Conclusions EVT was comparable to OS in terms of clinical outcomes in patients with acute SMAO. Some predictive factors for mortality or bowel resection were obtained. Clinical implications EVT may be a feasible alternative to OS, potentially impacting clinical practice as a less invasive option for managing patients with acute SMAO.In-hospital clinical outcomesInteraction effect test for mortality

Comparison of Endovascular Therapy and Open Surgical Revascularization in Patients With Acute Superior Mesenteric Artery Occlusion: A Large-Scale Analysis Based on the JROAD-DPC Database.

Acute mesenteric ischemia is rare, and few large-scale trials have evaluated endovascular therapy (EVT) and open surgical revascularization (OS). This study aimed to assess clinical outcomes after EVT or OS for acute superior mesenteric artery occlusion and identify predictors of mortality and bowel resection. Data from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC) database from April 2012 to March 2020 were retrospectively analyzed. Overall, 746 patients with acute superior mesenteric artery occlusion who underwent revascularization were classified into 2 groups: EVT (n=475) or OS (n=271). The primary clinical outcome was in-hospital mortality. The secondary outcomes were bowel resection, bleeding complications (transfusion or endoscopic hemostasis), major adverse cardiovascular events, hospitalization duration, and cost. The in-hospital death or bowel resection rate was ≈30%. In-hospital mortality (22.5% versus 21.4%, P=0.72), bowel resection (8.2% versus 8.5%, P=0.90), and major adverse cardiovascular events (11.6% versus 9.2%, P=0.32) were comparable between the EVT and OS groups. Hospitalization duration in the EVT group was 6 days shorter than that in the OS group, and total hospitalization cost was 0.88 million yen lower. Interaction analyses revealed that EVT and OS had no significant difference in terms of in-hospital death in patients with thromboembolic and atherothrombotic characteristics. Advanced age, decreased activities of daily living, chronic kidney disease, and oldmyocardial infarction were significant predictive factors for in-hospital mortality. Diabetes was a predictor of bowel resection after revascularization. EVT was comparable to OS in terms of clinical outcomes in patients with acute superior mesenteric artery occlusion. Some predictive factors for mortality or bowel resection were obtained. URL: www.umin.ac.jp/ctr/; Unique Identifier: UMIN000045240.

A Study of Predictors of Failure of Nonoperative Management of Ileocolic Intussusception in Children.

Surgery remains the mainstay in treating intussusception in developing nations. A correspondingly high bowel resection rate exists despite a shift to nonoperative reduction in high-income countries. We aimed to study the clinical profile of the patients with intussusception presenting to our hospital and to assess the clinical and radiological predictors of success or failure of nonoperative management of intussusception. This prospective study was conducted in the Department of Pediatric Surgery over a period of 3 years and included a total of 118 patients who presenting to our emergency division with features suggestive of intussusception and were managed accordingly either with hydrostatic reduction or by surgical intervention. We observed that the majority of the patients were males (65.5%). The mean age was 13.54 months. Intermittent pain was the most common symptom. Both pain and vomiting did not affect the outcome. Lab parameters like raised total leukocyte counts (TLC), C-reactive protein (CRP) and lactate levels were significantly associated with failure of hydrostatic reduction. Patients with air fluid levels on X-ray were more likely to end up in surgery. Ultrasound findings of bowel wall edema, aperistaltic gut loops and a pathological lead point was associated with failure of hydrostatic reduction as well. The overall success rate of hydrostatic reduction was 85.5%. Hydrostatic reduction of intussusception is a safe and effective method of management of intussusception whenever indicated. Factors that might reduce the chance of its success include continuous pain, irritability, tenderness, deranged lab parameters like TLC, CRP and lactate levels, air fluid levels on X-ray, bowel wall edema, aperistalsis and the presence of a lead point. Shah JY, Banday I, Hamdani HZ, et al. A Study of Predictors of Failure of Nonoperative Management of Ileocolic Intussusception in Children. Euroasian J Hepato-Gastroenterol 2024;14(1):81-85.

Access to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countries

Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition. This was a prospective, international, cohort study conducted between Jan 30 and May 21, 2023, in which any hospital performing inguinal hernia repairs was eligible to take part. Consecutive patients of any age undergoing primary inguinal hernia repair were included. A measurement set mapped to the attributes of WHO's Health System Building Blocks was defined to evaluate access (emergency surgery rates, bowel resection rates, and waiting times) and quality (mesh use, day-case rates, and postoperative complications). These were compared across World Bank income groups (high-income, upper-middle-income, lower-middle-income, and low-income countries), adjusted for hospital and country. Factors associated with postoperative complications were explored with a three-level multilevel logistic regression model. 18 058 patients from 640 hospitals in 83 countries were included, of whom 1287 (7·1%) underwent emergency surgery. Emergency surgery rates increased from high-income to low-income countries (6·8%, 9·7%, 11·4%, 14·2%), accompanied by an increase in bowel resection rates (1·2%, 1·4%, 2·3%, 4·2%). Overall waiting times for elective surgery were similar around the world (median 8·0 months from symptoms to surgery), largely because of delays between symptom onset and diagnosis rather than waiting for treatment. In 14 768 elective operations in adults, mesh use decreased from high-income to low-income countries (97·6%, 94·3%, 80·6%, 61·0%). In patients eligible for day-case surgery (n=12 658), day-case rates were low and variable (50·0%, 38·0%, 42·1%, 44·5%). Complications occurred in 2415 (13·4%) of 18 018 patients and were more common after emergency surgery (adjusted odds ratio 2·06, 95% CI 1·72-2·46) and bowel resection (1·85, 1·31-2·63), and less common after day-case surgery (0·39, 0·34-0·44). This study demonstrates that elective health care is essential to preventing over-reliance on emergency systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might strengthen non-surgical pathways too, reducing the burden on society and health services. NIHR Global Health Research Unit on Global Surgery and Portuguese Hernia and Abdominal Wall Society (Sociedade Portuguesa de Hernia e Parede Abdominal).

Managing ischemic and necrotic incarcerated femoral hernia contents and their risk factors.

Incarcerated femoral hernia patients had high risk of hernia contents necrosis. We provide our experience of management ischemia and necrosis of hernia contents in emergency incarcerated femoral hernia patients, and to investigate its risk factors. This is a case-control study. Eighty-nine incarcerated femoral patients who underwent emergency surgery from January 2015 to December 2021 were included, and divided into normal group (60 cases) and ischemia/necrosis group (29 cases) according to the intraoperative condition of hernia contents. The surgical methods, intraoperative and postoperative conditions were compared between the two groups. Multivariate logistic regression was used to analyze the risk factors of ischemia and necrosis of hernia contents. Open preperitoneal tension-free repair was the most commonly used surgical methods (68.5%) for incarcerated femoral patients. The utilization rate of laparoscopic repair in the ischemia/necrosis group was lower than that in the normal group (13.8% vs. 20.0%, P = 0.475). The proportion of mesh placement in the normal group was significantly higher than that in the ischemia/necrosis group (98.3% vs 65.5%, P < 0.001). The hernia contents resection rate (55.2% vs 1.7%), operation time (90 vs 40min), intraoperative bleeding (5 vs 2ml), ICU admission rate (31.0% vs 1.7%), and hospital stay (7 vs 4 d) were significantly higher in the ischemia/necrosis group than those in normal group. Results of multivariate logistic regression showed that incarceration time more than 9h (aOR = 19.3, 95%CI: 1.9-192.9) was an independent risk factor for ischemia and necrosis of hernia contents in emergency incarcerated femoral hernia patients. Open tension-free repair was the most commonly used surgical methods for emergency incarcerated femoral hernia patients. Ischemia and necrosis of hernia contents will increase bowel resection rate and prolong operation and hospital stay. Long incarceration time is an independent risk factor for ischemia and necrosis of hernia contents.

Suture repair versus mesh repair in elderly populations with incarcerated or strangulated groin hernia.

Tension-free hernia repair is the gold standard for groin hernia repair. However, the optimal surgical treatment for incarcerated or strangulated groin hernia in elderly populations is controversial. The aim of this study is to compare the clinical efficacy of mesh repair and suture repair in the treatment of incarcerated or strangulated groin hernia in elderly patients. Patients ≥ 65years who underwent urgent surgical repair for incarcerated or strangulated groin hernia from January 2012 to June 2022 were included. Patients' demographic data and postoperative outcomes were retrospectively analyzed. Patients with limited life expectancy were screened from the elderly population for subgroup analysis. A total of 103 patients (median age: 84years old, range 65-96; mean follow-up time: 36.8 ± 24.8months) were included, involving 42 cases in the suture repair group and 61 cases in the mesh repair group. Suture repair and mesh repair had similar lengths of ICU and hospital stay, and rates of small bowel resection, chronic pain, surgical site infection, and surgical-related death. However, suture repair had a significantly higher recurrence rate than mesh repair (7% vs. 2%, P = 0.04). In our subgroup analysis, for patients with limited life expectancy (41 patients; median age: 88yearsold, range: 80-96), suture repair had no statistical difference in postoperative outcomes compared with mesh repair. Mesh repair is suitable for elderly patients with acutely incarcerated or strangulated groin hernias. However, for elderly patients with limited life expectancy, suture repair and mesh repair showed similar clinical outcomes.

An inguinal surprise: strangulated femoral hernia

Femoral hernias account for 2% to 4% of groin hernias, are more common in women, and are more appropriate to present with strangulation and require emergency surgery. This condition may lead to symptoms of bowel obstruction or strangulation and possible bowel resection-anastomosis. There are few reports of strangulated femoral hernia. Femoral hernias, often, are usually delegated to a secondary differential or if even rarer not considered at all during dubious presentations as groin swellings which are irreducible without the classical features which have usually been described in our surgical literatures, Inguinal being forefront for diagnosis. We herein present a 45-year-old female had come to the outpatient department at MVJ MC and RH with the complaints of swelling in the left groin for 5 years and pain for 8 days sudden onset with irreducibility, with no features of small bowel obstruction. She was diagnosed as having a left side obstructed inguinal hernia after appropriate radiological investigations and underwent inguinal exploration. Intraoperative diagnosis of left sided strangulated femoral hernia with omentum as its content was made. Omentectomy with herniorrhaphy was done and post-operative period was uneventful, and patient was discharged with regular follow up. Femoral hernias are more common in women and lead to a substantial over risk for an emergency operation, and consequently, a higher rate of bowel resection and mortality. Femoral hernias should be operated with high priority to avoid incarceration and be repaired with a mesh.

Expanding the Use of HIPEC in Ovarian Cancer at Time of Interval Debulking Surgery to FIGO Stage IV and After 6 Cycles of Neoadjuvant Chemotherapy: A Prospective Analysis on Perioperative and Oncologic Outcomes

BackgroundRandomized data on patients with FIGO stage III ovarian cancer receiving ≤ 3 cycles of neoadjuvant chemotherapy (NACT) showed that hyperthermic intraperitoneal chemotherapy (HIPEC) after interval debulking surgery (IDS) improved patient’s survival. We assessed the perioperative outcomes and PFS of FIGO stage IV and/or patients receiving up to 6 cycles of NACT undergoing IDS+HIPEC.MethodsProspectively collected cases from January 1, 2019 to July 31, 2022 were included. Patients underwent HIPEC if: age ≥ 18 years but < 75 years, body mass index ≤ 35 kg/m2, ASA score ≤ 2, FIGO stage III/IV epithelial disease treated with up to 6 cycles of NACT, and residual disease < 2.5 mm.ResultsA total of 205 patients were included. No difference was found in baseline characteristics between FIGO Stage III and IV patients, whereas rate of stable disease after NACT (p = 0.004), mean surgical complexity score at IDS (p = 0.001), and bowel resection rate (p = 0.046) were higher in patients undergoing delayed IDS. A lower rate of patients with at least one G3–G5 postoperative complications was observed in FIGO stage IV versus FIGO stage III disease (5.3% vs. 14.0%; p = 0.052). This difference was confirmed at multivariable analysis (odds ratio [OR] 0.24; 95% confidence interval [CI] 0.07–0.80; p = 0.02), whereas age, SCS, bowel resection, and number of cycles did not affect postoperative complications. No difference in PFS was identified neither between FIGO stage III and IV patients (p = 0.44), nor between 3 and 4 versus > 4 cycles of NACT (p = 0.85).ConclusionsBecause of the absence of additional complications and positive survival outcomes, HIPEC administration can be considered in selected FIGO stage IV and patients receiving > 4 cycles of NACT.

A118 THE IMPACT OF HOMELESSNESS ON ENDOSCOPY UTILIZATION, SURGICAL TREATMENT, AND POST-OPERATIVE COMPLICATIONS AMONG HOSPITALIZED PATIENTS WITH CROHN’S DISEASE

Abstract Background Homelessness is an important public health issue with a prevalence around 4.2% in the United States. Homelessness has been associated with lack of access to healthcare services, poor quality of care, and negative health outcomes. However, there is limited data on clinical outcomes among homeless individuals with Crohn’s disease (CD). Aims In this study, we examine inpatient outcomes including endoscopy utilization, surgical treatment, and post-operative complications among homeless patients with CD. Methods The Healthcare Utilization Project (HCUP) State Inpatient Databases from New York, Arizona, Massachusetts and Florida for 2013 and 2014 were used to identify adults ≥18 years admitted with CD identified by International Classification of Diseases, Ninth Revision codes. Homeless patients were then identified, and propensity score matched using a one-to-ten greedy nearest-neighbor approach to non-homeless patients to balance the distribution of baseline covariates. Differences in outcomes including endoscopy utilization, surgical treatment and post-operative complications were reported as odds ratios (ORs) and 95% confidence intervals (CI). Results A total of 70,457 CD hospitalizations were identified, of which 469 (0.6%) were associated with homelessness. We matched 440 homeless patients with 4,400 housed patients with CD. Homeless individuals had a higher proportion of males (p=0.002), tended to be older (p=0.035), and had more comorbidities than non-homeless individuals. There was no difference in mortality between non-homeless and homeless patients (OR 1.6, 95% CI 0.72-3.57). Endoscopy utilization was comparable between non-homeless and homeless patients with CD including gastroscopy (OR 0.71, 95% CI 0.40-1.18), colonoscopy (OR 0.80, 95% CI 0.31-1.69), and sigmoidoscopy (OR 0.37, 95% CI 0.02-1.74) [Figure 1]. Surgical treatment was also comparable, except for lower rates of bowel resection among homeless patients (OR 0.55, 95% CI: 0.29-0.93). The two groups also had similar rates of post-operative complications including pulmonary, cardiovascular, gastrointestinal, and infectious complications (Figure 1). Conclusions Homeless patients with CD have comparable endoscopy utilization and surgical treatment as non-homeless patients, except for lower bowel resection rates. Postoperative complications are also similar between the two groups. Future studies are needed to better understand the impact of homelessness on health outcomes and healthcare service utilization among patients with CD. Figure 1. Endoscopy utilization, surgical treatment, and post-operative complications among homeless and non-homeless individuals using 1:10 propensity matching Funding Agencies None

P848 Risankizumab Effectiveness in Ustekinumab-naïve and Ustekinumab-experienced Patients with Crohn’s Disease- Real-world Data from a Large Tertiary Center

Abstract Background Risankizumab and ustekinumab are both IL23 inhibitors approved for treating moderate to severe Crohn’s disease (CD). They are distinguished by the fact that ustekinumab targets p40, the shared subunit of both IL23 and IL12, while risankizumab targets the p19 subunit and thus selectively inhibits IL23. The effectiveness of risankizumab in ustekinumab-experienced patients is of particular interest due to similar mechanisms of action. We present a large long-term real-world experience with risankizumab in ustekinumab-naïve and ustekinumab-experienced patients with CD. Methods We prospectively followed patients with CD treated with risankizumab in our center and documented their disease activity score at weeks 2, 4, 8, 12, 26, and 52 after treatment initiation. Patients treated for active luminal disease, defined as HBI≥5, fecal calprotectin≥250, or evidence of active disease per ileocolonoscopy or imaging were included. Patients who stopped treatment due to ineffectiveness or intolerance were counted as non-responders for the purpose of remission-rate calculation at each time point. Results 102 patients with CD with active luminal disease were treated with risankizumab and had at least 12 weeks of follow-up. Of them 46 (45%) were ustekinumab-naïve, and 56 (55%) were ustekinumab-experienced. The ustekinumab-experienced patients had longer disease duration and higher rates of prior bowel resection and exposure to multiple advanced therapies (Table 1). The baseline median HBI was higher in the ustekinumab-experienced group. Both groups had a continuous downward trend throughout the follow-up period (Figure 1A). At week 12, 74% (34/46) of the ustekinumab-naïve and 55% (31/56) of the ustekinumab-experienced patients achieved steroid-free clinical remission (SFCR) (P=0.06). At week 26, SFCR rates were 76% (25/33) and 60% (21/35) in ustekinumab naïve and experienced patients respectively (P=0.2). In a subgroup of patients with a follow-up of one year, 71% (5/7) and 40% (6/15) were in SFCR at week 52 (P=0.36) (Figure 1B). Of the patients who achieved SFCR at week 12, 85% in both groups maintained SFCR at week 26 (23/27 and 17/20 in ustekinumab-naïve and ustekinumab-experienced cohorts, respectively). Conclusion In this large real-world experience with long-term follow-up, we found that patients with CD treated with risankizumab were statistically similarly likely to achieve and sustain SFCR regardless of prior ustekinumab experience. Non-statistical differences noted may reflect the longer disease duration and prior treatment exposure of the ustekinumab-experienced group. These findings support the consideration of risankizumab as a treatment option for patients with CD regardless of their prior exposure to ustekinumab.

P1156 Characteristics and outcomes of over a million Inflammatory Bowel Disease patients in seven countries: a multinational cohort study

Abstract Background Population-based studies are crucial for gaining insights into epidemiology, risk factors, and outcomes of IBD. However, studies that characterize patient cohorts typically analyze a single resource, apply diverse eligibility criteria, and extract different sets of attributes. This study aims to address this gap by employing a unified data and analysis framework developed by the Observational Health Data Sciences and Informatics (OHDSI) community to longitudinally describe and compare IBD patient cohorts across multiple geographic regions. Methods Using routinely collected healthcare data harmonized to the OMOP Common Data Model, we longitudinally characterized IBD patient cohorts across diverse geographic regions. Data sources included insurance claims and electronic health records from primary and tertiary settings. IBD cohorts were defined based on diagnoses and medications, and stratified into various groups (e.g. by sex and age at diagnosis). Results We characterized disease trajectory of 462,502 Crohn’s disease (CD) and 589,118 ulcerative colitis (UC) subjects, in 16 databases (DBs) from seven countries worldwide (table 1). There was a noticeable trend toward a decrease in the average age at CD diagnosis in Europe and North America (e.g., 47.5 in 2005-2010 period to 44.3 in 2020-2022 at a US DB) contrasting with more stable patterns in Southeast Asia (e.g., 33.7 to 33.9 respectively in Japan). A similar, though weaker, decrease in diagnosis age has been observed in UC subjects. Prevalence rates of pre-diagnosis symptoms (abdominal pain, diarrhea, and rectal bleeding) were relatively stable over time, with minor differences between DBs. The proportion of females with anxiety was consistently higher across all datasets compared to males. Similarly, depression prevalence ranged between 11% to 46% in females and 0% to 33% in males. Examining surgical outcomes for CD patients, our study uncovered nuanced trends. While there hasn't been a significant decrease in colonic resection rates within one year following diagnosis between the early 2000s and 2020 in US populations, some DBs demonstrated increased resection rates over time (from 11% in 2005 to 14% in 2020 and from 5% to 11% in two different US DBs). A similar trend was observed when examining the colonic resection rate 3 years post diagnosis. Small bowel resection rates were stable along time among most DBs one- and three-years following diagnosis. Conclusion This study, leveraging OHDSI network data and tools, provides a comprehensive characterization of IBD patient cohorts from various areas. It furnishes valuable insights into disease trends, demographic variations, outcome, and pre-diagnosis symptoms in CD and UC contributing to a deeper understanding of IBD epidemiology

Utility of Enteral Contrast Protocols in Pediatric Adhesive Small Bowel Obstruction: A Prospective Multicenter Observational Study.

Our objective was to determine the utility of enteral contrast-based protocols in the diagnosis and management of adhesive small bowel obstruction (ASBO) for children. Enteral contrast-based protocols for adults with ASBO are associated with decreased need for surgery and shorter hospitalization. Pediatric-specific data are limited. We conducted a prospective observational study between October 2020 and December 2022 at nine children's hospitals who are members of the Western Pediatric Surgery Research Consortium. Inclusion criteria were children aged 1-20 years diagnosed with ASBO who underwent a trial of nonoperative management (NOM) at hospital admission. Comparisons were made between those children who received an enteral contrast challenge and those who did not. The primary outcome was need for surgery. We enrolled 136 children (71% male; median age: 12y); 84 (62%) received an enteral contrast challenge. There was no difference in rate of operative intervention between the no contrast (34.6%) and contrast groups (36.9%; P=0.93). Eighty-seven (64%) were successfully managed nonoperatively with no difference in median length of stay (P=0.10) or rate of unplanned readmission (P=0.14). Among the 49 children who required an operation, there was no significant difference in time from admission to surgery or rate of small bowel resection based on prior contrast administration. The addition of enteral contrast-based protocols for management of pediatric ASBO does not decrease the likelihood of surgery or shorten hospitalization. Larger randomized studies may be needed to further define the role of radiologic contrast in the management of ASBO in children.

Comparison of early operative treatment and 48-hour conservative treatment in small bowel obstruction (COTACSO): intermediate results

A RCT is devoted to outcomes of early operative treatment and NOM for adhesive SBO. The estimated trial capacity is 200 patients. Thirty-two patients were included in interim analysis. In 12 hours after admission, patients without apparent signs of strangulation were randomized into two clinical groups after conservative treatment. Group I included 12 patients who underwent immediate surgery, group II - 20 patients after 48-hour NOM. The primary endpoint was success of non-surgical regression of SBO and reduction in mortality. To evaluate patient safety, we analyzed mortality, complication rates and bowel resection in this RCT with previously published studies. In group I, all 12 (100%) patients underwent surgery. Only 4 (20%) patients required surgery in group II. Mortality, complication rates and bowel resection rates were similar in both groups. Strangulating SBO was found in 8 (25%) patients. Overall mortality was 6.3%, bowel resection rate - 6.3%, iatrogenic perforation occurred in 3 (18.8%) patients. These values did not exceed previous findings. Non-operative management within 48 hours prevented surgery in 80% of patients with SBO. Interim analysis found no significant between-group differences in mortality, complication rates and bowel resection rate. Patients had not been exposed to greater danger than other patients with adhesive SBO. The study is ongoing.

Safety of Biologics and Small Molecules for Inflammatory Bowel Diseases in Organ Transplant Recipients.

This study aimed to evaluate the safety of biologics and small molecules for the treatment of inflammatory bowel diseases (IBD) in patients receiving antirejection therapies after organ transplants. We reviewed the medical records of patients with IBD who received organ transplants at the Asan Medical Center between January 1989 and December 2021. We compared the parameters of patients receiving biologics or small molecules to those of patients without those therapies. This study included a total of 53 patients (ulcerative colitis, 41; Crohn's disease, 6; and gastrointestinal Behçet's disease, 6). Among them, 15 patients were receiving biologics or small molecules and 38 were not. During a mean follow-up of 119 months, the proportion of patients experiencing severe infections was significantly higher in those treated with biologics or small molecules than in those not treated. However, other safety outcomes (e.g., malignancies, adverse events, including organizing pneumonia or hepatic failure, and death) were not different between the two groups. Kaplan-Meier curve analysis revealed no significant difference in the safety outcome rate related to the use of biologics or small molecules. During follow-up, eight patients underwent bowel resections for IBD. The rate of bowel resection was not different between the two groups. The use of biologics or small molecules for patients with IBD who received organ transplants did not show a significant difference in safety outcomes. However, the possibility of severe infections must be considered.

Construction and validation of a predictive model for the risk of bowel resection in adults with incarcerated groin hernia

BackgroundIt is difficult to definitively determine the degree of ischemia in the bowel in which an incarcerated groin hernia is embedded. Failure to diagnose and intervene promptly and accurately increases the rate of bowel resection and patient mortality. The aim of this study is to investigate the risk factors for incarcerated inguinal hernia complicating bowel necrosis with resection and to establish a predictive model as a reference for clinical work.MethodsPatients with incarcerated groin hernia who were admitted to our hospital were retrospectively analyzed. They were divided into bowel resection and non-bowel resection groups based on whether bowel resection was performed in the surgical record and postoperative pathological results. Risk factors for the development of bowel resection in incarcerated groin hernia were analyzed by univariate analysis and multivariate logistic regression, respectively. The screened independent risk factors were used to establish a prediction model, and finally, the predictive ability and accuracy of the model were validated and the clinical benefit was analyzed.ResultsA total of 345 patients with incarcerated groin hernia were included, of whom 58 underwent bowel resection for bowel necrosis and 287 did not. Multifactorial logistic regression analysis identified bowel obstruction (OR, 7.285 [95% CI, 2.254–23.542], P = 0.001), peritonitis (OR, 16.786 [95% CI, 5.436–51.838], P = 0.000), duration of incarcerated groin hernia (OR, 1.009 [95% CI, 1. 001-1.018], P = 0.034), heart rate (OR, 1.109 [95% CI, 1.021–1.205], P = 0.014), and preoperative total protein (OR, 0.900 [95% CI, 0.836–0.969], P = 0.005) were independent risk factors for bowel resection in incarcerated groin hernia. The predictive value of the established prediction model was basically in agreement with the measured value with a consistency index of 0.938 (0.901–0.974) and had a good clinical benefit.ConclusionClinical screening and management of independent risk factors for bowel resection in patients with incarcerated groin hernia should be strengthened. The predictive model developed in this study has high diagnostic efficacy for bowel resection associated with incarcerated inguinal hernia, with the aim of reducing the incidence of bowel resection and unplanned secondary surgery.

Notable Clinical Differences Between Neonatal and Post-Neonatal Intestinal Malrotation: A Multicenter Review in Southern Japan

BackgroundMost cases of intestinal malrotation appear in neonates with bilious vomiting due to midgut volvulus, whereas in cases that develop beyond infancy, the initial symptoms vary. This study investigated the clinical features of these two populations and identified issues that should be considered in daily practice. MethodsA retrospective chart review was conducted from January 1, 2010, to December 31, 2022. Data on patients with intestinal malrotation were collected in an anonymized fashion from five pediatric surgical hub facilities in the Southern Kyushu and Okinawa areas of Japan. ResultsOf the 80 subjects, 57 (71.3%) were neonates (Group N) and 23 (28.7%) were infants and schoolchildren (Group I). The frequencies of initial symptoms, such as abdominal distention (Group N: 19.3% vs. Group I: 13.0%), bilious vomiting (59.6% vs. 43.5%), and hematochezia (8.8% vs. 21.7%), were not skewed by the age of onset (p = 0.535, 0.087, and 0.141, respectively). Midgut volvulus was significantly more frequent in Group N (71.9% [41/57] vs. 34.8% [8/23]; p = 0.005), while the degree of torsion was greater in group I (median 360° [interquartile range: 180–360°] vs. 450° [360–540°]; p = 0.029). Although the bowel resection rate was equivalent (7.0% [4/57] vs. 4.3% [1/23]; p = 1.000), half of the patients in Group N presented with 180° torsion. The neonatal intestine has been highlighted as being more susceptible to ischemia than that in older children. ConclusionsThe incidence of midgut volvulus is higher in neonates than in older children. Even relatively mild torsion can cause ischemic bowel changes during the neonatal period. Level of EvidenceLEVEL III.

Very low risk of short bowel after Roux-en-Y gastric bypass – a large nationwide Swedish cohort study

BackgroundRoux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures. Internal herniation may lead to small bowel ischemia requiring small bowel resection, resulting in short bowel syndrome. ObjectiveTo determine the incidence of extensive small bowel resection in patients operated with RYGB. We also aimed to look for early clinical warning signs among patients requiring extensive small bowel resection. SettingCohort from national quality registers. MethodsAll patients having undergone RYGB between January 2007 to June 2019 were analyzed in the Scandinavian Obesity Surgery Registry (SOReg). We identified patients with small bowel obstruction (SBO) for whom small bowel resection was necessary. Additionally, we assessed clinical signs in these patients. ResultsThe study included 57,255 patients having undergone RYGB. Closure of the mesenteric openings was performed in 78%. Surgery for SBO was required in 3659 (6%) of patients, and small bowel resection in 188 (.3%). Extensive small bowel resection, resulting in less than 1.5 meters of remaining small bowel, was required in 7 patients (.01%). All patients with extensive small bowel resection presented with abdominal pain and had confirmed internal herniation as the cause of the small bowel resection, and 2 of 7 patients died. Closure of mesenteric defects was not associated with a reduction in overall small bowel resection rates (P = .89) ConclusionSurgery for SBO after RYGB was common (6%). The risk of extensive small bowel resection leading to short bowel was low (.01%). Patients with abdominal pain after RYGB should be assessed for internal hernia, as it can be devastating.

A Comparative Study of Laparoscopic versus Open Management of Index Small Bowel Obstruction in Children

IntroductionThere is limited literature on the optimal approach to treat adhesive small bowel obstruction (ASBO) in children. We sought to compare rates and outcomes of laparoscopic (LAP) and open (OPEN) surgery for pediatric ASBO. MethodsA California statewide database was used to identify children (<18 years old) with an index ASBO from 2007 to 2020. The primary outcome was the type of operative management: LAP or OPEN. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications. We excluded patients treated non-operatively. ResultsOur study group had 545 patients. 381 (70%) underwent OPEN and 164 (30%) LAP during the index admission. Over the study period, there was increasing use of laparoscopic surgery, with higher use in older children (p < 0.001). LAP was associated with fewer overall complications (65.2% vs. 81.6%, p < 0.001), with a decreasing trend in complications over time (p < 0.001). The LAP group had significantly lower rates of bowel resection (4.9% vs. 17.1%, p < 0.001), length of stay (LOS) (17 vs. 23 days, p < 0.001), and TPN use (12.2% vs. 29.1%, p < 0.001). Mortality rates were equivalent. Although the LAP group had lower readmission rates (22.6% vs. 37.3%, p < 0.001), the length of time between discharge and readmission was similar (171 vs. 165 days, p = 0.190). DiscussionThe use of laparoscopic surgery for index ASBO increased over the study period. However, it was less commonly utilized in younger children. LAP had fewer overall complications as well as shorter LOS, decreased TPN use, and fewer readmissions. The benefits and risks of each approach must be weighed. Level of evidenceIII.

Neo-adjuvant chemotherapy does not reduce surgical complexity nor the accuracy of intra-operative visual assessment of disease in advanced ovarian cancer

AimCompare the surgical complexity and histological accuracy of visual inspection of disease in patients undergoing primary debulking (PDS) versus delayed debulking surgery (DDS) following neo-adjuvant chemotherapy (NACT) for advanced ovarian cancer (AOC). Materials and methodsAll patients undergoing PDS or DDS for stage III / IV AOC at a UK cancer centre between January 2014–October 2021 were included. Retrospective data was collected accessing an electronic gynaecological oncology database, operation and histology records. Comparative frequencies of surgical procedures performed were calculated for primary versus delayed cohorts; and correlation between intra-operative suspicion of disease and specimen histology at PDS and DDS compared. ResultsN=232. PDS was performed in 45.3% and DDS in 54.7% of patients; achieving complete cytoreduction in 77.2%. Appendicectomy, pelvic and para-aortic nodal dissection were undertaken significantly more often at primary surgery; whilst right diaphragm stripping, pelvic peritonectomy, splenectomy and cholecystectomy were more likely following NACT. We found no variation in bowel resection rates between cohorts. For the majority of specimens, there was no difference in correlation between intra-operative suspicion of disease and final histopathology – with a significantly lower positive predictive value for visual assessment demonstrated only for liver capsule and pelvic peritoneum at DDS. ConclusionNACT does not appear to reduce the complexity of surgery, including rates of bowel resection; nor accuracy of intra-operative visual assessment of disease. We therefore caution against both deferring to NACT to facilitate less radical delayed debulking; and any presumption that macroscopically abnormal tissue at DDS may represent inert post-NACT ‘burn-out’, mitigating indication for excision. We instead suggest reservation of the neo-adjuvant pathway for patients with poor PS and radiologically-confirmed surgical stopping points; and advocate equivalent and maximal cytoreductive effort to remove all visibly abnormal tissue in both the upfront and delayed surgical settings.

Trends in Management of Index Adhesive Small Bowel Obstruction in Children

IntroductionTo examine practice patterns and surgical outcomes of nonoperative versus operative management (OPM) of children presenting with an index adhesive small bowel obstruction (ASBO). MethodsA California statewide health discharge database was used to identify children (<18 y old) with an index ASBO from 2007 to 2020. The primary study outcome was evaluating initial management patterns (nonoperative versus OPM and early [≤3 d] versus late surgery [>3 d]) of ASBO. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications. ResultsOf the 2297 patients identified, 1948 (85%) underwent OPM for ASBO during the index admission. Of these, 14.7% underwent early surgery within 3 d. Teaching hospitals had higher operative intervention than nonteaching centers (87.1% versus 83.7%, P = 0.034). OPM was the highest in 0-5-year-olds compared to other ages (89% versus 82%, P < 0.001). In comparison to early surgery, late surgery was associated with longer length of stay (early 7[interquartile range 5-10], late 9[interquartile range 6-17], P < 0.001), increased infectious complications (16.4% versus 9.8%, P = 0.004), and greater use of total parenteral nutrition (28.0% versus 14.3%, P = 0.001); there was no difference in bowel resection (21% versus 18%, P = 0.102) or mortality (P = 0.423). ConclusionsOur pediatric study demonstrated a high rate of OPM for index ASBO, especially in newborns and toddlers. Although operative intervention, especially late surgery, was associated with increased length of stay, increased infectious complications, and increased total parenteral nutrition use, the rates of bowel resection and mortality did not differ by management strategy. These trends need to be further evaluated to optimize outcomes.