Subsequent Small Bowel Obstruction Research Articles

Risk of Reopening of the Mesenteric Defects After Routine Closure in Laparoscopic Roux-en-Y Gastric Bypass: a Single-Centre Experience.

Small bowel obstruction (SBO) due to internal hernias (IH) is a well-recognised complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). Routine closure of the mesenteric defects (MDs) is recommended to reduce the risk of IH and subsequent SBO. However, data about the rates of reopening of the MDs after LRYGB is scarce. The main aim of this study was to evaluate the risk of reopening of the MDs after routine closure during LRYGB. The secondary objective was to determine any risk factors associated with the reopening of the MDs. Data of all patients who underwent reoperations after LRYGB with closure of both MDs between January 2010 and December 2018 were retrospectively reviewed. A total of 162 patients were included. The median time between LRYGB and reoperation was 17months. At the time of reoperation, both MDs were closed in 83 patients (51.2%); thus, 79 patients (48.8%) presented at least one open MD. The group of patients with preoperative diagnosis of SBO or with recurrent abdominal pain showed significantly higher rates of open Petersen's space compared to the group of patients with other preoperative diagnoses. Preoperative body mass index (BMI) less than 40kg/m2 at time of LRYGB was associated with a higher risk for an open MD. At least one MD reopened in almost half of the patients despite routine closure during LRYGB. Therefore, the status of MDs should be routinely examined during every reoperation after LRYGB and closure of open MDs should be performed.

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

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

Operative treatment for intussusception: Should an incidental appendectomy be performed?

Background/objectivesAn incidental appendectomy is performed by some surgeons during operative treatment for intussusception to eliminate future appendicitis as a diagnostic consideration. However, an appendectomy can increase the risk of infection and other noninfectious complications making an incidental appendectomy controversial. We examined outcomes for surgical intervention for intussusception with appendectomy (SWA) compared to surgical reduction alone (SRA). MethodsThe Pediatric Health Information System database, 8/2008–9/2015, was retrospectively analyzed for patients under the age of five who required an operative intervention for intussusception without bowel resection. Demographic data and postoperative outcomes were analyzed. Available data included need for postoperative enema, subsequent small bowel obstruction, recurrent intussusception, length of stay (LOS), and adjusted total cost (ATC). ResultsFifty-seven percent (748/1312) of patients had appendectomy performed during surgical reduction, 564 (43%) did not. ATC ($10,594 vs. $8939, p < 0.001) and LOS (3.0 vs. 2.48, p < 0.001) are higher in the SWA group. Rates of readmission are similar, but post-operative small bowel obstruction may be higher in the SWA group (1.3% vs. 0.35%, p = 0.06). ConclusionThere is a higher mean LOS and ATC in the SWA group. This study suggests that appendectomy during surgery for uncomplicated intussusception should be reconsidered and requires further investigation. Type of Studyretrospective comparative study. Level of EvidenceIII.

Decreased risk of surgery for small bowel obstruction after laparoscopic colon cancer surgery compared with open surgery: a nationwide cohort study.

The impact of surgical approach on the incidence of small bowel obstruction (SBO) is unclear. The aim of the current study was to analyze the long-term risk of surgery for SBO after open and laparoscopic surgery and to assess how subsequent SBO surgery impacts on mortality after colonic cancer resection. This was a nationwide cohort study of patients undergoing elective colonic cancer resection with primary anastomosis in Denmark between 2001 and 2008. All included patients were operated with curative intent. Patients were identified in the Danish Colorectal Cancer Group database and followed through May 2014 in the Danish National Patient Register. The primary endpoint was surgery for SBO. Secondarily, mortality among patients who subsequently underwent SBO surgery and those who did not was compared. Among the 8583 included patients, 251 (2.9%) underwent surgery for SBO during follow-up (median 8.8years). The 3-year cumulative incidence of SBO surgery was 1.5%; 1.2% after laparoscopic and 1.6% after open surgery. Laparoscopic surgery was associated with a decreased risk of SBO (hazard ratio [HR] 0.61 (CI 0.37 to 0.99, P=0.048) compared with open surgery. The HR for mortality after colonic resection was 2.54 (CI 1.91 to 3.38, P<0.001) for patients who underwent subsequent SBO surgery as compared to those who did not. Laparoscopic surgery for colonic cancer was associated with a decreased risk of subsequent SBO surgery compared with open surgery. Further, subsequent SBO surgery was associated with increased mortality after colonic cancer resection.

Bowel obstructions and incisional hernias following trauma laparotomy and the nonoperative therapy of solid organ injuries: A retrospective population-based analysis.

Small bowel obstruction (SBO) and incisional hernia (IH) represent the most common long-term complications of laparotomy. They may also be more common among injured patients than for elective/nontrauma emergency scenarios. Unfortunately, the population-based incidence of SBO and IH following trauma laparotomy is unknown. The aim of this study was to define the long-term, population-based incidence of SBO and IH following both trauma laparotomy as well as the nonoperative therapy of solid organ injuries. All injured patients admitted to a Level 1 trauma center (2002-2013) who underwent (1) a laparotomy or nonoperative care of (2) splenic and/or (3) hepatic injuries were linked with the Alberta Health Services Discharge Database to identify all readmissions for subsequent SBO and/or IH within the province. Standard statistical methodology was used (p < 0.05). Of 484 patients who underwent a trauma laparotomy, 29 (6%) and 42 (9%) required readmission for SBO and IH, respectively (0.13 SBO and 0.10 IH admissions per patient year). Patients who underwent nonoperative management of their liver and/or spleen injuries displayed long-term SBO rates of 1% (6 of 619) and 0.7% (4 of 606), respectively. The rate of SBO and IH in patients with unnecessary laparotomies was equivalent to therapeutic procedures (p = 0.183). Topical hemostatic agents, repeat laparotomies, and injury pattern did not alter SBO or IH rates (p > 0.05). The population-based, long-term rate of clinically relevant SBO and IH following trauma laparotomies is 15%. This increases to 19% on a per-admission basis. Nontherapeutic scenarios, injury pattern, topical hemostatics, and open abdomens did not alter complication rates. Therapeutic study, level IV.

Endoloop as the First Line Tool for Appendiceal Stump Closure in Children with Appendicitis

The objective of this study is to compare outcomes for pediatric patients undergoing laparoscopic appendectomy (LA) performed either (1) using an endostapler (ES) to divide the appendix and mesoappendix or (2) using endoloops (ELs) to close the appendiceal stump and electrocautery to divide the mesoappendix. We conducted a retrospective chart review of all patients who underwent LA for suspected appendicitis 4 years at a free standing children's hospital. The use of EL and ES was compared separately in patients with perforated and nonperforated appendicitis. We compared patient characteristics and outcomes. There were no significant differences in rate of postoperative abscess, rate of subsequent small bowel obstruction requiring operation or rate of intraperitoneal hematoma between the ES and EL groups for both nonperforated and perforated appendectomy cases. Superficial wound infection was more common in the nonperforated EL group (17/309, 5.5%) than in the nonperforated ES group (2/235, 0.9%; p = 0.007). Operative time for the EL technique (52.2 ± 15.8 minutes; p = 0.047) was shorter than for the ES technique (58 ± 23.2 minutes) for patients with perforated appendicitis. EL stump closure and mesoappendix cauterization during LA is safe and effective in children with appendicitis, including perforated appendicitis.

Adhesion Prevention During Laparotomy

The objective of the study was to determine the long-term effect of the use of a hyaluronic acid-carboxymethylcellulose membrane (Seprafilm) on the incidence of adhesions and subsequent small-bowel obstruction and chronic abdominal complaints after colorectal surgery (Hartmann's procedure). Adhesions occur frequently after abdominal surgery and are the most common cause of bowel obstruction, chronic abdominal pain, and infertility. The risk for adhesion-related readmission in the first 10 years after colorectal surgery is as high as 30%. To reduce the formation of adhesions, a mechanical barrier composed of hyaluronic acid and carboxymethylcellulose was developed, to prevent adherence of tissues after abdominal surgery. Long-term results concerning the incidence of small-bowel obstruction and chronic abdominal pain are lacking. Between April 1996 and September 1998, 71 patients requiring Hartmann's procedure for sigmoid diverticulitis or obstructed rectosigmoid were randomized to either intraperitoneal placement of Seprafilm under the midline and in the pelvis or as a control. Direct visual evaluation of the incidence and severity of adhesions was performed laparoscopically in 42 patients at second-stage surgery for restoration of the continuity of the colon. The results of this study were published in 2002. In 2006, the patients' general practitioners were interviewed by means of a questionnaire concerning their patients' health. The patients who were still alive were interviewed and asked to fill out 2 questionnaires concerning pain and quality of life (VAS-pain score, EQ-5D, and SF-36). In 2009, the medical records of the patients were evaluated for adhesion-related hospital re-admissions. Of the 42 evaluated patients, 35 (16 in the Seprafilm group, 19 in the control group) could be enrolled in the long-term follow-up. Median follow-up was 126 months (range 41-148) for the Seprafilm group and 128 months (range 49-149) months for the control group. Incidence of chronic (3 months or longer existing) abdominal complaints was significantly lower in the Seprafilm group compared with controls (35.3% vs. 77.8%, respectively; P = 0.018). Incidence of small-bowel obstruction showed no significant difference in favor of the Seprafilm group; no small-bowel obstructions occurred in the Seprafilm group, whereas in the control group 2 cases of small-bowel obstruction were found to have occurred. Evaluation of the quality of life questionnaires did not reveal significant differences between the 2 groups. In Hartmann's procedure, Seprafilm placement does not provide protection against small-bowel obstruction. Incidence of chronic abdominal complaints is significantly lower after use of Seprafilm.

Temporary Use of a Fully Covered Self-Expandable Metal Stent for Treatment of Bariatric Surgery Complications

Purpose: Fully covered self expandable metal stents (FCSEMS) have been used in selected cases to manage post-bariatric surgical complications, though the data are limited. Such complications include gastric body strictures (sleeve gastrectomy), anastomotic strictures (Roux-en-Y gastric bypass), and fistulae. Aim: To report the outcome following FCSEMS placement for management of post-bariatric surgery complications using one type of FCSEMS. Methods: The medical records of all patients having undergone placement of one type of FCSEMS (Alimaxx-E, Merit Medical Systems, Inc.) from 1/1/2005 to 5/17/2010 were reviewed after IRB consent was obtained. 165 patients were initially identified and 15 of these had a FCSEMS placed exclusively to treat a complication resulting from bariatric surgery or surgical revision of a prior bariatric surgery. Data were abstracted for patient demographics, indications for stent placement, technical success, clinical outcomes, and stent related complications. Results: The 15 patients (mean age 48 years, 10 female) included 11 Rouxen-Y gastric bypass, 3 duodenal switch, and one sleeve gastrectomy patient. Indications for FCSEMS placement were stricture (9 patients), fistula (3 patients), and both stricture and fistula (3 patients). A total of 20 attempted FCSEMS placements occurred at a mean time of 514 days after surgery (range 14-1640 days). Technical success with placement was achieved in 19/20 attempts. Mean stent dwell time was 63 days. Endoscopic resolution of stricture was seen in 9/12 (75%) of stricture patients at time of stent removal, however, 7 of these patients developed recurrent strictures. Improvement in fistula was seen in 2/6 patients and did not required re-intervention up to 12 months after stent removal. Complications included 6 stent migrations, 2 of which lodged in the distal small bowel; one of these also caused a perforation and both required surgical removal/repair. A third stent migrated into the colon and was endoscopically removed. All other stents were completely removed by upper endoscopy; stent fragmentation during removal occurred in one case and was without sequela. Ultimately, 8/16 patients underwent surgery due to stricture recurrence or persistent fistulae despite FCSEMS placement. Conclusion: 1) Temporary placement of FCSEMS alone for management of post-bariatric surgery complications appears to have limited efficacy, with poor to moderate long term results. 2) Stent migration with subsequent small bowel obstruction or perforation was observed, and 50% of all patients required surgery for ultimate correction of their primary problem. 3) Adjuvant therapy such as fibrin glue could potentially improve outcome of fistula closure. Disclosure: Dr Johan C. Bakken: No financial disclosures Dr Wong Kee Song: No financial disclosures Dr Todd Baron - Paid Speaker: Alveolus, Inc.

Bowel Obstruction Following Appendectomy

Appendicitis is a common problem that is typically treated with an appendectomy. Following abdominal surgery, adhesions may form and may cause a subsequent small bowel obstruction (SBO). The purpose of our study was to determine the rate of post-appendectomy SBO in an adult population, and to observe any difference in SBO rates between open versus laparoscopic appendectomies. All patients who underwent an appendectomy at an adult hospital in the Calgary Health Region between 1999 and 2002 were identified by using the administrative discharge database. Pathology and operative technique (laparoscopic, McBurney incision, midline laparotomy) were reviewed. Using those regional health numbers, any further admissions with a diagnostic code for bowel obstruction were identified. Medical charts (n = 1777) were reviewed to confirm the rate of post-appendectomy SBO. A logistic regression was performed to identify risk factors of post-appendectomy SBO and expressed as odds ratios (95% confidence interval). The overall SBO rate was 2.8% over an average 4.1-year follow-up period. The risk factors for developing SBO following appendectomy for appendicitis included, perforated appendicitis (odds ratio [OR] = 3.1, 95% confidence interval [CI]: 1.5-6.6), and midline incisions (OR = 5.4, 95% CI: 2.8-10.4). Those with pathology of cancer or chronic appendicitis conferred the greatest overall risk of SBO (OR = 7.4, 95% CI: 2.7-20.3). The rate of SBO following appendectomy in adults was 2.8%, or 0.0069 cases per person-year. The greatest risk factors for developing SBO were midline incision and nonappendicitis pathology. There is no statistically significant difference in SBO rates following laparoscopic appendectomy compared with open approaches.

Abdominal Complications Related to Type of Repair for Congenital Diaphragmatic Hernia

Literature on congenital diaphragmatic hernia (CDH) over the past few decades has focused on prognostic factors and management of pulmonary hypertension/hypoplasia. Larger diaphragmatic defects may require patch closure, reported by some authors to be associated with poorer outcomes. In this study, we evaluate the impact synthetic material has on the need for subsequent abdominal operations, particularly recurrence and small bowel obstruction (SBO). After obtaining IRB approval, all patients undergoing repair of congenital diaphragmatic from January, 1994 to December, 2004 were investigated. Records from primary and subsequent admissions were reviewed to identify those patients who underwent major procedures after repair of the diaphragmatic defect. Subsequent abdominal operations in these series were recurrent CDH repair, exploration for SBO and fundoplication. Patients who died prior to hospital discharge were excluded. Statistical comparisons were made using Fisher's exact test: significance was defined as P<0.05. During the study period, there were 81 survivors from CDH repair, 24 with a synthetic patch, and 57 without. Those with a patch repair had a significantly increased risk of recurrence, small bowel obstruction, and subsequent operation (Table 1). Eleven patients had nonabsorbable mesh patches, and 13 were repaired with absorbable (Surgisis-Gold; Cook Technology Inc., West Lafayette, IN). While there were no differences in recurrence between these two groups, four patients (31%) with Surgisis developed SBO compared with one patient (9%) repaired with a nonabsorbable synthetic. Incidence of SBO and recurrent CDH in patients with a patch was higher than those who underwent primary repair. There may also be a difference in the rate of subsequent SBO depending on the type of mesh used. A prospective trial is under way at our institution to help define this issue.

P241: Abdominal complications related to type of repair for congentital diaphragmatic hernia

Introduction: Literature on congenital diaphragmatic hernia (CDH) over the past few decades has focused on prognostic factors and management of pulmonary hypertension/hypoplasia. Larger diaphragmatic defects may require patch closure, reported by some authors to be associated with poorer outcomes. In this study, we evaluate the impact synthetic material has on the need for subsequent abdominal operations, particularly recurrence and small bowel obstruction (SBO). Methods: After obtaining IRB approval, all patients undergoing repair of congenital diaphragmatic from January, 1994 to December, 2004 were investigated. Records from primary and subsequent admissions were reviewed to identify those patients who underwent major procedures after repair of the diaphragmatic defect. Subsequent abdominal operations in theis series were recurrent CDH repair, exploration for SBO and fundoplication. Patients who expired within the first year of life were excluded. Statistical comparisons were made using Fisher’s exact test: significance was defined as P < 0.05. Results: During the study period, there were 81 survivors from CDH repair, 24 with a synthetic patch, and 57 without. Those with a patch repair had a significantly increased risk of recurrence, small bowel obstruction and subsequent operation (Table 1). Eleven patients had non-absorbable mesh patches, and 13 were repaired with absorbable (Surgisis® - Gold™). While there were no differences in recurrence between these two groups, 4 patients (31%) with Surgisis® developed SBO compared to 1 patient (9%) repaired with a non-absorbable synthetic. Conclusions: Incidence of SBO and recurrent CDH in patients with a patch was higher than those who underwent primary repair. There may also be a difference in the rate of subsequent SBO depending on the type of mesh used. A prospective trial is underway at our institution to help define this issue. Table 1 Primary Closure (N=57) Patch Repair (N=24) P-Value Small Bowel Obstruction 3 (5%) 5 (21%) 0.046 Recurrence 4 (7%) 6 (25%) 0.020 Fundoplication 6 (11%) 5 (21%) 0.29 Subsequent abdominal operation 10 (18%) 15 (63%) < 0.001 Open table in a new tab

A case of enterolith ileus

A 78-year-old lady presented with abdominal pain and subsequent small bowel obstruction due to stone impaction. The patient had had a previous cholecystectomy making the many jejunal diverticulae the most likely source of the stone. This is a case of small bowel obstruction made distinctive by the cause of enterolith impaction. Paul Wilson is a consultant surgeon with University Hospitals of Morecambe Bay NHS Trust.

Jejunojejunal Anastomotic Obstruction Following Laparoscopic Roux-en-Y Gastric Bypass Due to Non-Absorbable Suture: A Report of Seven Cases

Small bowel obstruction (SBO) is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). We describe 7 cases of jejunojejunal anastomotic obstruction related to adhesion formation after closure of the mesenteric "leaves" defect with non-absorbable suture. All patients undergoing LRYGBP from October 2002 until February 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with SBO were analyzed. Jejunojejunal anastomotic obstruction occurred in 7 out of 152 patients (4.6%) in whom LRYGBP was performed from October 2002 to February 2004. Since February 2004, the suture used to close the jejunojejunal mesenteric leaves defect was changed from non-absorbable Dacron (Surgidac) to absorbable suture material. The mean interval between initial LRYGBP and subsequent SBO was 153 days. Operative findings common to all 7 cases were dilated loops of proximal small bowel, and a single adhesion just distal to the Roux-Y anastomosis. Following adhesiolysis, each patient had prompt return of bowel function without recurrence of obstruction. Of the 156 patients who have since undergone LRYGBP, none have presented with SBO, and this difference is statistically significant (P=0.008). The overall rate of SBO (2.3%) is consistent with the previous literature, although the incidence of adhesions specifically at the jejunojejunal anastomosis is higher than that previously encountered. It appears that the incidence of postoperative SBO at the jejunojejunal anastomosis is directly linked to the choice of suture material intraoperatively. As such, absorbable suture should be used to close the jejunojejunal mesenteric leaves defect.

Mechanical Small Bowel Obstruction due to Intraluminal Thrombus in a Patient with Acute Leukaemia: Ultrasonic Findings

Conventional plain film radiography is the primary imaging procedure in cases of suspected bowel obstruction. With improvement in ultrasound (US) technology, it can be used as part of the evaluation of patients with an acute abdomen [1–3]. US can detect the level of bowel obstruction accurately, particularly in the presence of a gasless, fluid-filled plain abdominal film [4]. We report an unusual case of gastrointestinal bleeding and subsequent small bowel obstruction caused by thrombus in a patient with acute leukaemia. The diagnosis was based on the US findings and confirmed at emergency surgery. To our knowledge, such a case has been not described previously.

Effectiveness of Intestinal Tube Splinting: A Prospective Observational Study

Background/Aims: To assess the effectiveness of intestinal tube splinting. Patients and Methods: The clinical, operative and outcome data of 186 patients undergoing 200 intestinal splinting procedures from 1973 until 1996 were accumulated in a prospective database. Endpoints were perioperative morbidity, mortality and the incidence of subsequent small bowel obstruction (SBO). The latest follow-up performed in 1998 updated the outcome of 197 procedures after 1–25 (median 7) years. Results: In the early postoperative period, the overall incidence of complications was 9%, procedural complications 2%, and repeat surgery 3%. Three patients died during the index hospitalization. No patient suffered early SBO. Between 1 and 13 years after splinting, 6 complete SBOs (3%) necessitated reoperation and 5 incomplete SBOs (2.5%) were managed conservatively. After splinting for late SBO, freedom from complete SBO was 0.989 and of incomplete SBO 0.906, after splinting for early SBO 0.872 and 0.972, respectively, and for segmental peritonitic SBO freedom from complete SBO 0.8. No obstruction followed prophylactic splinting. Conclusions: Splinting was a reasonably safe procedure with comparatively low morbidity and mortality. The procedure prevented early SBO in all indicatory subgroups, reduced the rate of late recurrent SBO in patients treated for late adhesive SBO as compared with historical outcome data of simple enterolysis and prevented late SBO when performed prophylactically.

Small bowel obstruction secondary to enzymatic digestion of a gastric bezoar

Paralleling the increased frequency of vagotomy as an ulcer treatment as well as the more routine use of fiberoptic postoperative endoscopy, the recognition of an intestinal bezoar has become fairly common. This case is presented to describe an uncommon complication after partial enzymatic dissolution of a gastric bezoar causing subsequent small bowel obstruction.

Complications and results of 160 Baker tube plications

The basic indication for Baker tube plication is widespread enteric serosal injury. The prediction of subsequent small bowel obstruction remains difficult. Consequently, the benefits of Baker tube plication cannot be clearly defined. A therapeutic decision must be made by weighing the known facts. In this series of 160 Baker tube plications, the incidence of tube complications was 7 percent. Witzel tunnel construction of the jejunostomy was judged important in reducing the complications of this procedure. The incidence of recurrent obstruction was 9 percent with an average follow-up period of 3.9 years.