Risk Of Small Bowel Obstruction Research Articles

Type of Prior Operation Does Not Predict Surgical Intervention for Small Bowel Obstruction.

Background: Patients with prior abdominal surgeries are at higher risk for intra-abdominal adhesive tissue formation and subsequently higher risk for small bowel obstruction (SBO).Purpose: In this study, we investigated whether surgical intervention for SBO was more likely following specific types of abdominal surgeries.Research Design: With retrospective chart review, we pooled data from 799 patients, ages 18 to 89, admitted with SBO between 2012 and 2019. Patients were evaluated based on whether they underwent surgery or were managed conservatively. They were further compared with regard to past surgical history by way of type of abdominal surgery (or surgeries) undergone prior to admission.Results: Of the 799 patients admitted for SBO, 206 underwent surgical intervention while 593 were managed nonoperatively. There was no significant difference in number of prior surgeries (2.07±1.56 vs 2.36±2.11,P = .07) or in number of comorbidities (2.39±1.97 vs 2.65±1.93,P= .09) for surgical vs non-surgical intervention. Additionally, of the operations evaluated, no specific type of abdominal surgery predicted need for surgical intervention in the setting of SBO. However, for both surgical and non-surgical intervention following SBO, pelvic surgery was the most common type of prior abdominal surgery (45% vs 43%). There are significantly more female pelvic surgeries in both the operative (91.4% vs 8.6%,P< .0001) and nonoperative groups (89.9% vs 10.2%,P< .0001).Conclusion: Ultimately, no specific type of prior operation predicted the need for surgical intervention in the setting of SBO.

Analysis of abdominal adhesion using the ileostomy model.

Abdominal adhesion occurs commonly in clinical practice, causing unfavorable symptoms and readmission. The ileostomy operation is a common surgical procedure and we utilized this model to evaluate abdominal adhesion. Adhesion grade score was calculated in 35 patients (Cohort 1) and subjected to correlation and receiver operating characteristic analysis. Then 98 consecutive patients (Cohort 2) who underwent ileostomy and ileostomy closure were included into a retrospective study. Logistic regression analysis was performed, and the risk of small bowel obstruction was also assessed. The time of ileostomy closure correlated with adhesion grade score in Cohort 1, justifying its use as an indicator of abdominal adhesion. All patients in Cohort 2 were then divided into the high- and low-adhesion group. A multi-variable logistic regression analysis indicated that type of surgery and peritoneum suture during ileostomy were significant factors affecting the risk of abdominal adhesion. Abdominal adhesion had the trend to prolong the length of stay postoperatively without increasing the risk of bowel obstruction. Nine patients suffered bowel obstruction, and age older than 65 significantly increased the risk. We proposed the ileostomy procedure to be a model of abdominal adhesion, and the operative time of ileostomy closure could be used as an alternative of adhesion score. Type of surgery and peritoneum suture may be risk factors of abdominal adhesion. Older age increased the risk of small bowel obstruction after ileostomy surgery.

WTP4.1 Can Deep Stomal Fixation and Extraperitoneal Stoma Creation Improve Stoma Morbidity? Systematic Review and Meta-Analysis

Abstract Aim This systematic review evaluates the efficacy and safety of two operative techniques: deep stomal fixation (fixation of stoma to the sheath of abdominal wall muscles and/or peritoneum) and extraperitoneal approach of stoma creation. Method PubMed, Medline, Cochrane, and Google Scholar were searched for studies comparing stoma fixation to the sheath and/or peritoneum to the conventional skin-only fixation and extraperitoneal to transperitoneal approaches of stoma formation. Clinical endpoints included parastomal hernia (PSH), stoma prolapse, retraction and associated adverse effects. Results 2 randomised and 2 retrospective studies investigated deep stomal fixation. There was no statistically significant benefit of this technique in terms of PSH (OR 1.19, P=0.82), prolapse (OR 0.62, P=0.53) or retraction (OR 1.16, P=0.80). Some technical difficulties on stoma reversal were reported in one of the studies. As for extraperitoneal stoma creation, 2 randomised and 8 retrospective studies compared it to the conventional transperitoneal approach. A statistically notable reduction in PSH was identified in extraperitoneal stomas (OR 0.29, P=0.004). This technique showed statistically insignificant reduction in prolapse (OR 0.74, P=0.53) and retraction (OR 0.48, P=0.36). There was no significant difference in operative time (MD 3.45, P=0.71) or the associated risk of small bowel obstruction (OR 0.68, P=0.57). Conclusion Stoma fixation to the abdominal muscle sheath and/or peritoneum does not lower stomal complications, and conversely it may make stoma reversal technically challenging. Extraperitoneal approach minimises PSH occurrence with no remarkable adverse effects; yet more randomised trials are required for further evaluation.

The effect of routine division of the greater omentum on small bowel obstruction after Roux-en-Y gastric bypass.

It remains unknown whether routine division of the greater omentum during laparoscopic Roux-en-Y gastric bypass (LRYGB) influences the risk for small bowel obstruction (SBO) after RYGB. To evaluate the effect of omental division on SBO after LRYGB stratified by handling of the mesenteric defects. Nationwide, registry-based. In this registry-based cohort study, 40,517 patients who underwent LRYGB in Sweden within the period from January 1, 2007, to December 31, 2019, with data from the Scandinavian Obesity Surgery Registry (SOReg) were included. The study was based on combined data from the SOReg, the National Patient Register, the Swedish Prescribed Drugs Register, and the Total Population Registry. The main outcome was reoperation for SBO. During a follow-up period of 5.9 ± 2.6 years, the cumulative incidence of SBO was 11.2% in the nondivision group compared with 9.7% among patients with divided omentum (hazard ratio [HR] = .83, 95% confidence interval [CI]: .77-.89, P < .001). The association was seen in patients without mesenteric defects closure (HR = .69, 95% CI: .61-.78, P < .001) as well as patients with closed mesenteric defects (HR = .80, 95% CI: .74-.87, P < .001). Division of the greater omentum is associated with reduced risk for SBO after antecolic, antegastric LRYGB and should be considered as a complement to mesenteric defects closure to further reduce the risk for SBO after LRYGB.

Internal Hernia After Laparoscopic Left Colectomy: Case Series and Review of the Literature

Abstract Objective Laparoscopic colectomy has gained acceptance as a standard treatment for benign and malignant colorectal disease, such as diverticular disease and cancer, among others. Same as in open surgery, the laparoscopic approach carries a low risk of small bowel obstruction in the postoperative period, but in laparoscopic surgery, internal hernia after laparoscopic left colectomy may be a cause of small bowel obstruction with a significant risk of morbidity and mortality. This rare complication may be prevented with routine closure of the mesenteric defects created during the colectomy. Methods We present four cases of internal herniation after laparoscopic colectomy. Two cases were after laparoscopic left colectomy and two after laparoscopic low anterior resection. All four cases had full splenic flexure mobilization. Routine closure of the mesenteric defect was not performed in the initial surgery. Results The four patients were treated by laparoscopic reintervention with closure of the mesenteric defect. In two of them, conversion to open surgery was necessary. One of the patients developed recurrent internal herniation after surgical reintervention with mesenteric closure of the defect. All patients were managed without need for bowel resection, and mortality rate was 0%. Conclusion Internal herniation after laparoscopic colorectal surgery is a highly morbid complication that requires prompt diagnosis and management and should be suspected in the early postoperative period. Additional studies with extended follow-up are required to establish recommendations regarding its prevention and management.

Surgical technique in constructing the jejunojejunostomy and the risk of small bowel obstruction after Roux-en-Y gastric bypass.

Mechanical problems at the level of the jejunojejunostomy (JJ) have been identified as a cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (RYGB). The objective of the study was to investigate associations between specific surgical techniques used to construct the JJ and the subsequent risk of SBO. Nationwide Registry, Sweden. The risk of SBO after primary RYGB surgery during 2012-2019 was assessed using data from the Scandinavian Obesity Surgery Registry and the Swedish National Patient Register. The impact of unidirectional or bidirectional stapling and length of the mesenteric division (0, 1-4, or ≥5 cm) at the JJ was analyzed with adjustments for known covariates. We analyzed outcomes from 23,448 patients (mean follow-up = 4.3 ± 2.2 yr). In multivariate analysis, bidirectional stapling of the JJ was associated with a reduced 30-day risk of SBO (hazard ratio [HR] = .52, 95% confidence interval [CI] = .29-.95, P < .05), whereas limited mesenteric division (1-4 cm) increased the risk of SBO (HR = 1.66, 95% CI = 1.14-2.42, P < .01). The long-term incidence of SBO was increased by bidirectional stapling but unaffected by mesenteric division. However, mesenteric division decreased the long-term risk of SBO in patients with a bidirectionally stapled JJ (1-4 cm, HR = .59, 95% CI = .38-.90, P < .05; ≥5 cm, HR = .30, 95% CI = .14-.65, P<.005). The surgical technique for construction of the JJ may affect the incidence of SBO after RYGB surgery.

SP10.1.6 Effect of hyaluronate-based bioresorbable membrane (Seprafilm) on outcomes of abdominal surgery: a meta-analysis and trial sequential analysis of randomised controlled trials

Abstract Background We aimed to evaluate comparative outcomes of abdominal surgery with and without hyaluronate-based bioresorbable membrane (Seprafilm). Methods We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits. Small bowel obstruction, anastomotic leak, surgical site infections, ileus, and severity of adhesions were the evaluated outcome measures. Results Thirteen randomised controlled trials reporting a total of 3,665 patients evaluating outcomes of abdominal surgeries with (n=1,800) or without (n=1,865) use of Seprafilm were identifed. Use of Seprafilm was associated with significantly lower risk of small bowel obstruction (RR:0.53, 95% CI 0.38–0.73, P=0.0001) but significantly higher rate of anastomotic leak (RR: 1.85, 95% CI 1.15–3.00 P=0.01). Moreover, while Seprafilm resulted in significantly more adhesions-free patients (RR:5.57, 95% CI 3.37–9.19, P&amp;lt;0.0001) compared to no Seprafilm, its use was associated with significantly lower grade 2 (RR:0.57, 95% CI 0.35–0.95, P=0.003) or 3 (RR:0.31, 95% CI 0.17–0.55, P&amp;lt;0.0001) adhesions. There was no significant difference in surgical site infection (RR:1.21, 95 CI 0.86–1.70, P=0.28), intra-abdominal abscess (RR: 1.46, 95 CI 0.92–2.32, P=0.11) or paralytic ileus (RR:0.97, 95 CI 0.68–1.38, P=0.87) between two groups. The trial sequential analysis demonstrated that the meta-analysis findings are conclusive. Conclusions Seprafilm reduces the risk of small bowel obstruction and severity of adhesions after abdominal surgery. However, it may increase the risk of anastomotic leak. We recommend use of Seprafilm in any abdominal surgery which does not involve an anastomosis.

Effect of hyaluronate-based bioresorbable membrane (Seprafilm) on outcomes of abdominal surgery: a meta-analysis and trial sequential analysis of randomised controlled trials.

We aimed to evaluate comparative outcomes of abdominal surgery with and without hyaluronate-based bioresorbable membrane (Seprafilm).We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits. Small bowel obstruction, anastomotic leak, surgical site infections, ileus, and severity of adhesions were the evaluated outcome measures. Thirteen randomised controlled trials reporting a total of 3665 patients evaluating outcomes of abdominal surgeries with (n = 1800) or without (n = 1865) use of Seprafilm were identified. Use of Seprafilm was associated with significantly lower risk of small bowel obstruction (RR 0.53, 95% CI 0.38-0.73, P = 0.0001) but significantly higher rate of anastomotic leak (RR 1.85, 95% CI 1.15-3.00 P = 0.01). Moreover, while Seprafilm resulted in significantly more adhesions-free patients (RR 5.57, 95% CI 3.37-9.19, P < 0.0001) compared to no Seprafilm, its use was associated with significantly lower grade 2 (RR 0.57, 95% CI 0.35-0.95, P = 0.003) or 3 (RR 0.31, 95% CI 0.17-0.55, P < 0.0001) adhesions. There was no significant difference in surgical site infection (RR: 1.21, 95 CI 0.86-1.70, P = 0.28), intra-abdominal abscess (RR 1.46, 95 CI 0.92-2.32, P = 0.11) or paralytic ileus (RR 0.97, 95 CI 0.68-1.38, P = 0.87) between two groups. The trial sequential analysis demonstrated that the meta-analysis findings are conclusive. Our meta-analysis demonstrated that Seprafilm reduces the risk of small bowel obstruction and severity of adhesions after abdominal surgery. However, it may increase the risk of anastomotic leak. We recommend use of Seprafilm in any abdominal surgery which does not involve an anastomosis.

Probabilistic Risk Assessment of Prophylactic Surgery Before Extended-Duration Spaceflight.

Introduction. Prophylactic surgery before spaceflight may eliminate the risk of appendicitis and cholecystitis in astronauts on deep space missions. However, even minimally invasive surgery increases the risk of small bowel obstruction (SBO). Probabilistic risk assessment (PRA) is a method that can be used to estimate the benefits and risks of prophylactic surgery. Methods. Risks of appendicitis and cholecystitis during a 2.5-year Mars mission are compared to the risk of SBO after laparoscopic removal of the appendix, gallbladder, or both. A PRA model using Monte Carlo methodology was used to forecast the risks. Results. Prophylactic appendectomy and cholecystectomy combined, conferred an increased probability of medical evacuation (pEVAC) due to SBO as compared to the no surgery group. A slightly higher probability for the loss of crew life (pLOCL) was found in the no surgery group when compared to the cases in which either prophylactic appendectomy alone, or appendectomy plus cholecystectomy are performed. Discussion. The need for medical evacuation can be viewed as a potential risk for death in the context of a space mission where evacuation is not possible. Because of the higher pEVAC due to SBO and relatively small benefit in the reduction of pLOCL in the prophylactic surgery groups, this analysis does not support the prophylactic removal of appendix and/or gallbladder for spaceflight. Future advances in surgical or medical technique or mission medical capabilities may change these results. This work demonstrates the utility of PRA in providing quantitative answers to "what if" questions where limited information is available.

The Optimal Feeding Enterostomy Creation During Esophagectomy to Reduce the Long-Term Risk of Small Bowel Obstruction.

Although feeding jejunostomy (FJ) is commonly created during esophagectomy for postoperative enteral nutrition, it can be a cause of postoperative small bowel obstruction (SBO). We introduced a technique of feeding enterostomy using the round ligament of the liver (FERL) to reduce SBO. In this study, we aimed to clarify the efficacy of FERL in reducing the postoperative SBO compared with FJ. We assessed 400 consecutive patients who underwent esophagectomy with gastric tube reconstruction between 2011 and 2016, before and after the introduction of FERL (FJ, n = 200; FERL, n = 200). The cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy were compared between the FJ and the FERL groups. Thoracoscopic and laparoscopic surgery was more frequent in the FERL group than in the FJ group (p < 0.001). The cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy in the FERL group were significantly less frequent than those in the FJ group (p < 0.001 and p = 0.006, respectively). When stratifying by the abdominal surgical approach, the cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy in a laparoscopic approach were less frequent in the FERL group than those in the FJ group (both p < 0.001). The FERL technique can reduce the incidences of postoperative SBO and SBO associated with feeding enterostomy in patients undergoing esophagectomy.

A Nationwide Cohort Study of Outcome after Pediatric Appendicitis.

Children with appendicitis often present with complicated disease. The aim of this study was to describe the clinical management of pediatric appendicitis, and to report how disease severity and operative modality are associated with short- and long-term risks of adverse outcome. A nationwide retrospective cohort study of all Swedish children (<18 years) diagnosed with appendicitis, 2001 to 2014 (n = 38,939). Primary and secondary outcomes were length of stay, surgical site infections, readmissions, 30-day mortality, and long-term risk of surgery for small bowel obstruction (SBO). Implications of complicated disease and operative modality were assessed with adjustment for age, gender, and trends over time. Complicated appendicitis was associated with longer hospital stay (4 vs. 2 days, p < 0.001), increased risk of surgical site infection (5.9 vs. 2.3%, adjusted odds ratio [aOR]: 2.64 [95% confidence interval, CI: 2.18-3.18], p < 0.001), readmission (5.5 vs. 1.2, aOR: 4.74 [95% CI: 4.08-5.53], p < 0.001), as well as long-term risk of surgery for SBO (0.7 vs. 0.2%, adjusted hazard ratio [aHR]: 3.89 [95% CI: 2.61-5.78], p < 0.001). Intended laparoscopic approach was associated with reduced risk of surgical site infections (2.3 vs. 3.1%, aOR: 0.74 [95% CI: 0.62-0.89], p = 0.001), but no overall reduction in risk for SBO; however, successful laparoscopic appendectomy was associated with less SBO during follow-up compared with open appendectomy (aHR: 0.27 [95% CI: 0.11-0.63], p = 0.002). Children treated for complicated appendicitis are at risk of substantial short- and long-term morbidities. Fewer surgical site infections were seen after intended laparoscopic appendectomy, compared with open appendectomy, also when converted procedures were accounted for.

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.

377 Developing a Nomogram to Enhance Point-of-Care Ultrasound Utility in Predicting Small Bowel Obstruction Diagnosis and Outcome

Predicting the diagnosis and a need for surgical intervention in patients with small bowel obstruction (SBO) can assist with emergency physicians’ decisions in selecting appropriate management strategy in the ED. We developed and validated a unique nomogram for the prediction of SBO diagnosis based on clinical features and point-of-care ultrasound (POCUS) findings. We used data from a prospective cohort of patients in a single-institution database that consisted of 125 patients with suspected SBO who underwent POCUS evaluation in the ED of a tertiary academic center. Patients’ demographic and clinical data were collected, including age, sex, history of SBO, comorbidities, prior abdominal surgery, and clinician’s pre-test probability of SBO was surveyed prior to POCUS or CT scan results. Data from this cohort were analyzed to develop a nomogram integrating age, sex, comorbidities, prior abdominal surgery, physician’s pre-test probability, and POCUS findings to determine post-test risk of SBO. The associations of relevant clinical and demographical variables and POCUS findings with SBO diagnosis were assessed using Cox proportional hazards regression models. The discriminative ability of the nomogram was tested using C statistics, calibration plots, and Kaplan-Meier curves. The derivation cohort included 125 patients with a median age of 54 years who underwent POCUS for a suspected SBO. One-fourth of the patients (25.6% [32/125]) had SBO, and (10% [12/125]) underwent a surgical intervention. Using a retrospective stepwise selection of clinically important variables with the POCUS results, the final nomogram incorporated four relevant factors for the prediction of SBO: dilated loop of small bowel of at least 2.5 cm (hazard ratio [HR], 0.10; 95% CI, 0.04-0.16; P < .001), positive inter-luminal fluid (HR, 2.10; 95% CI, 0.96-3.24; P < .001), clinician’s high pretest probability (HR, 2.42; 95% CI, 0.36-4.48; P=0.021), and patient age (HR, 0.03; 95% CI, -0.00 to 0.07; P = 0.08). The discriminative ability and calibration of the nomogram revealed good predictive ability as indicated by the C statistic of 0.89 for the SBO diagnosis. A unique nomogram was developed to utilize the function of patient age, POCUS findings of small bowel > 2.5 cm in diameter, inter-luminal fluid, and pretest probability before POCUS to accurately predict the diagnosis of SBO. The nomogram was able to stratify patients into prognostic groups and performed well on internal validation. The nomogram should be prospectively validated in a novel cohort of patients at risk for SBO.

Comparing Techniques for Mesenteric Defects Closure in Laparoscopic Gastric Bypass Surgery\u2014a Register-Based Cohort Study

BackgroundRoutine closure of mesenteric defects is generally considered standard part of laparoscopic gastric bypass surgery today. Controversy still exists regarding the optimal method for mesenteric defects closure. The objective was to compare different methods for mesenteric defects handling in laparoscopic gastric bypass surgery.MethodsPrimary laparoscopic gastric bypass procedures from 2010 until 2015 reported to the Scandinavian Obesity Surgery Registry (SOReg), where the mesenteric defects closure method was identifiable, were included. Main outcome measures were serious postoperative complication within 30 days after surgery, and reoperation for small bowel obstruction within 5 years after surgery. Quality-of-life before and after surgery, duration of surgery, and risk factors for complication were also analyzed. Information on operation for small bowel obstruction was based on data from the SOReg, the Swedish National Patient Register and reviews of hospital charts.ResultsIn all, 34,707 patients were included. Serious postoperative complication occurred in 174 (2.9%) patients with sutures, in 592 (3.1%, adjusted p = 0.079) with clips, and 278 (3.1%; adjusted p = 0.658) in the non-closure group. Reoperation for small bowel obstruction within 5 years after surgery was lower with sutures (cumulative incidence 6.9%) and clips (cumulative incidence 7.3%; adjusted HR 1.16, 95% CI 1.02–1.32, p = 0.026), compared to non-closure (cumulative incidence 11.2%; adjusted HR 1.63, 95% CI 1.44–1.84, p < 0.0001).ConclusionClosure of the mesenteric defects using either non-absorbable metal clips or non-absorbable running sutures is a safe and effective measure to reduce the risk for small bowel obstruction after laparoscopic gastric bypass surgery. Sutures appear slightly more effective and should remain gold standard for mesenteric defects closure.

Pregnancy As a Risk Factor for Small Bowel Obstruction After Laparoscopic Gastric Bypass Surgery.

To evaluate whether pregnancy is associated with increased risk for small bowel obstruction after laparoscopic gastric bypass surgery. Small bowel obstruction is a common and feared long-term complication to laparoscopic gastric bypass surgery that may be more common during pregnancy. It is unclear if the risk truly increases during pregnancy. Women, 18 to 55 years, operated with a primary laparoscopic gastric bypass procedure from 2010 until 2015 were identified through the Scandinavian Obesity Surgery Registry (n = 25,853). Through record-linkage to the Medical Birth Registry, the National Patient Registry, and review of hospital charts, information on pregnancy periods and outcome were obtained. The main outcome was operation due to small bowel obstruction after the laparoscopic gastric bypass procedure. Pregnancy was associated with increased risk for small bowel obstruction following laparoscopic gastric bypass surgery (incidence rates 46.5, 95% CI 38.0-56.9/1000 person-years, vs 20.9 95% CI 19.9-22.0; adjusted-HR 1.72, 95% CI 1.39-2.12, P < 0.001). While no excess risk was observed during the first trimester, the second (adjusted-HR 1.67, 95% CI 1.17-2.39, P = 0.005) and third (adjusted-HR 2.69, 95% CI 2.02-3.59, P < 0.001) conferred increased risk. The incidence rate of small bowel obstruction during pregnancy was 42.9 (95% CI 32.4-57.0/1000 person-years) among women for whom the mesenteric defects had been closed during the primary procedure, and 53.2 (95% CI 38.9-72.8/1000 person-years) for women in whom they had been left open. Pregnancy is associated with increased risk for small bowel obstruction after laparoscopic gastric bypass surgery during the second and third trimesters.

Impact of mesenteric defect closure technique on complications after gastric bypass

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

Effect of Cesarean Delivery on Long-term Risk of Small Bowel Obstruction.

To evaluate the association of cesarean deliveries on the incidence of small bowel obstruction. We formed a population-based cohort of all women with a first live birth between 1998 and 2007 using the U.K. Clinical Practice Research Datalink. Women were followed until 2015, the occurrence of a small bowel obstruction, or loss to follow-up. Cesarean delivery was identified from the Hospital Episode Statistics and small bowel obstruction events were identified using the Classification of Interventions and Procedures and International Classification of Diseases, 10th Revision codes. Cox proportional hazard models, with cesarean delivery defined as a time-dependent exposure, estimated the adjusted hazard ratios and 95% CIs of small bowel obstruction associated with cesarean delivery. The cohort included 81,480 women with a median follow-up of 8.0 years (range 6 months to 16.6 years), during which 575 new small bowel obstructions occurred (incidence 9.1/10,000 person-years). Risk of small bowel obstruction was higher among women with a cesarean delivery compared with women without (16.3 vs 6.4 patients/10,000 person-years, odds ratio [OR] 2.54, 95% CI 2.15-3.00). Increasing number of cesarean deliveries was associated with an increasing risk of small bowel obstruction (OR 1.61, 95% CI 1.46-1.78, per additional cesarean delivery). Repeated small bowel obstructions were more common among women with a cesarean delivery and the association remained when restricting to small bowel obstruction requiring surgical management. Although rare, small bowel obstructions are increased among women who have undergone a cesarean delivery. With increasing rates of cesarean deliveries worldwide, small bowel obstructions and related morbidities may become a more prevalent women's health concern.

Simple ligation versus stump inversion in open appendicectomy: a systematic review and meta-analysis

To perform a systematic review and meta-analysis on post-operative complications after surgery for appendicitis comparing simple ligation with inversion of the appendix stump. PubMed, Medline and Embase databases were searched to identify studies comparing post-operative outcomes in appendicectomy following simple ligation and inversion of the appendix stump. A meta-analysis with a random-effects model was used to calculate pooled odds ratios (OR) and confidence intervals (CI) for each outcome measure of interest. A total of 14 studies were included for meta-analysis, comprising a total of 4037 patients who underwent appendicectomy. There was an increased risk of small bowel obstruction following appendix stump inversion (OR = 4.18, CI = 1.31 – 13.41; p = 0.02; 9 studies). After excluding studies without antibiotic prophylaxis there was no difference between inversion or ligation of the appendix stump with respect to either total infective complications (OR = 1.03; 95% CI= 0.75 – 1.43, 10 studies) or surgical site infection (OR = 1.07; CI = 0.78 – 1.47; 10 studies). Inversion of the appendix stump during appendicectomy may increase risk post-operative small bowel obstruction whilst offering no reduction in post-operative infective complications.

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

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

Health-Related Quality-of-Life after Laparoscopic Gastric Bypass Surgery with or Without Closure of the Mesenteric Defects: a Post-hoc Analysis of Data from a Randomized Clinical Trial

BackgroundMesenteric defect closure in laparoscopic gastric bypass surgery has been reported to reduce the risk for small bowel obstruction. Little is known, however, about the effect of mesenteric defect closure on patient-reported outcome. The aim of the present study was to see if mesenteric defect closure affects health-related quality-of-life (HRQoL) after laparoscopic gastric bypass.MethodsPatients operated at 12 centers for bariatric surgery participated in this randomized two-arm parallel study. During the operation, patients were randomized to closure of the mesenteric defects or non-closure. This study was a post-hoc analysis comparing HRQoL of the two groups before surgery, at 1 and 2 years after the operation. HRQoL was estimated using the short form 36 (SF-36-RAND) and the obesity problems (OP) scale.ResultsBetween May 1, 2010, and November 14, 2011, 2507 patients were included in the study and randomly assigned to mesenteric defect closure (n = 1259) or non-closure (n = 1248). In total, 1619 patients (64.6%) reported on their HRQoL at the 2-year follow-up. Mesenteric defect closure was associated with slightly higher rating of social functioning (87 ± 22.1 vs. 85 ± 24.2, p = 0.047) and role emotional (85 ± 31.5 vs. 82 ± 35.0, p = 0.027). No difference was seen on the OP scale (open defects 22 ± 24.8 vs. closed defects 20 ± 23.8, p = 0.125).ConclusionWhen comparing mesenteric defect closure with non-closure, there is no clinically relevant difference in HRQoL after laparoscopic gastric bypass surgery.