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Reintam Blaser A, Koitmäe M, Laisaar KT, Forbes A, Kase K, Kiisk E, Murruste M, Reim M, Starkopf J, Tamme K. Radiological diagnosis of acute mesenteric ischemia in adult patients: a systematic review and meta-analysis. Sci Rep 2025; 15:9875. [PMID: 40119151 PMCID: PMC11928508 DOI: 10.1038/s41598-025-94846-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2025] [Accepted: 03/17/2025] [Indexed: 03/24/2025] Open
Abstract
Computed tomography (CT) is widely used in diagnosing acute mesenteric ischemia (AMI), but robust identification of distinctive subtypes and stages of progression is lacking. Systematic literature search in PubMed, Cochrane Library, Web of Science and Scopus was conducted in May 2024. Studies including at least 10 adult patients and reporting radiological diagnosis of AMI versus no AMI or transmural ischemia versus no transmural ischemia were included. Meta-analyses on sensitivity and specificity of different radiological features in diagnosing AMI were conducted. From 2628 titles, 490 studies underwent full text review, and 81 were included in 14 meta-analyses. Diagnostic accuracy of CT angiography (CTA) was high - sensitivity of 92.0% and specificity of 98.8% (I2 45% and 79%, respectively), but lower for other CT protocols (sensitivity 75.8 and specificity 90.5; I2 83%). In most included studies, distinction of subtypes and severity of AMI (non-transmural or transmural) was not possible. Amongst the non-vascular features, absent/reduced bowel wall enhancement provided the best prognostic value (sensitivity 57.9 and specificity 90.1). CTA is the method of choice for diagnosing AMI with high diagnostic accuracy. None of the non-vascular features alone is sufficiently reliable to diagnose AMI or its progression to transmural necrosis, whereas a combination of different radiological features conveys a potential.
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Affiliation(s)
- Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Merli Koitmäe
- Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Kaja-Triin Laisaar
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Karri Kase
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of General and Plastic Surgery, Tartu University Hospital, Tartu, Estonia
| | - Ele Kiisk
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Marko Murruste
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of General and Plastic Surgery, Tartu University Hospital, Tartu, Estonia
| | - Martin Reim
- Department of Radiology, Tartu University Hospital, Tartu, Estonia
| | - Joel Starkopf
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Kadri Tamme
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
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Räty P, Bonsdorff A, Parviainen H, Lantto E, Hackenberg T, Lampela H, Nykänen T, Lyytinen I, Mentula P, Sallinen V. Development and external validation of prediction risk scores (STRISK and NOFA) to predict immediate surgical need in adhesive small bowel obstruction: an observational prospective multicentre study. Br J Surg 2025; 112:znaf025. [PMID: 40105480 PMCID: PMC11921420 DOI: 10.1093/bjs/znaf025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Revised: 10/26/2024] [Accepted: 01/16/2025] [Indexed: 03/20/2025]
Abstract
BACKGROUND Adhesive small bowel obstruction (SBO) is a common cause of emergency admission. Identification of patients at high risk of strangulation or failure of non-operative treatment is difficult. In this multicentre prospective observational study, prediction models for strangulation and non-operative treatment failure in adhesive SBO were developed. METHOD This study was carried out in three Finnish hospitals between June 2014 to May 2022. Patients with CT-confirmed adhesive SBO and prospective case report forms were included. The main outcomes were strangulation defined by operative finding of any intestinal ischaemia and failure of non-operative treatment within 30 days from admission. The model was developed using binary logistic regression, internally validated by bootstrapping and then externally validated. RESULTS Of 626 patients, 481 were included; 355 patients formed the model development group and 126 formed the external validation group. Strangulation occurred in 58 (16%) patients and non-operative treatment failed in 93 (31%) patients in development cohort. The following six variables were included in the risk model for strangulation and non-operative treatment failure: neutrophil-leucocyte ratio, number of previous SBOs, abdominal guarding, mesenteric changes and free abdominal fluid, closed loop sign, and faeces sign on CT. In the development cohort, the optimism corrected area under the receiver operator characteristics curve for the strangulation model was 0.860 (95% c.i. 0.808-0.917), and 0.751 (95% c.i. 0.694-0.816) for the non-operative treatment failure model respectively. At external validation, the models retained their discrimination and demonstrated stable calibration. CONCLUSION A clinically relevant prediction model to predict strangulation and non-operative treatment failure in adhesive small bowel obstruction has been developed.
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Affiliation(s)
- Panu Räty
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Akseli Bonsdorff
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Helka Parviainen
- HUS Medical Imaging Center, Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Eila Lantto
- HUS Medical Imaging Center, Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Hanna Lampela
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Taina Nykänen
- Department of Surgery, Hyvinkää Hospital, Hyvinkää, Finland
| | - Ilana Lyytinen
- Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Panu Mentula
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Wang Z, Zhu L, Liu S, Li D, Liu J, Zhou X, Wang Y, Liu R. Development and validation of a CT-based radiomic nomogram for predicting surgical resection risk in patients with adhesive small bowel obstruction. BMC Med Imaging 2025; 25:46. [PMID: 39934668 DOI: 10.1186/s12880-025-01575-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Accepted: 01/28/2025] [Indexed: 02/13/2025] Open
Abstract
BACKGROUND Adhesive small bowel obstruction (ASBO) is a common emergency that requires prompt medical attention, and the timing of surgical intervention poses a considerable challenge. Although computed tomography (CT) is widely used, its effectiveness in accurately identifying bowel strangulation is limited. The potential of radiomics models to predict the necessity for surgical resection in ASBO cases is not yet fully explored. OBJECTIVES The aim of this study is to identify risk factors for surgical resection in patients with ASBO and to develop a predictive model that integrates radiomic features with clinical data. This model designed to estimate the likelihood of surgical intervention and aid in clinical decision-making for acute ASBO cases. METHODS From January 2019 to February 2022, we enrolled 188 ASBO patients from our hospital, dividing them randomly into a training cohort (n = 131) and a test cohort (n = 57) using a 7:3 ratio. We collected baseline clinical data and extracted radiomic features from CT images to compute a radiomic score (Rad-score). A nomogram was developed that combines clinical characteristics and Rad-score. The performance of clinical, radiomic, and combined nomogram models was evaluated in both cohorts. RESULTS Of the 188 patients, 92 underwent surgical resection, while 96 did not. The nomogram integrated factors such as white blood cell count, duration of obstruction, and preoperative infection indicators (fever, tachycardia, peritonitis), along with CT findings (elevated wall density, thickened wall, mesenteric fluid, ascites, bowel wall gas, small bowel feces, and hyperdensity of mesenteric fat) (p < 0.1). This combined model accurately predicted the need for surgical resection, with area under the curve (AUC) values of 0.761 (95% CI, 0.628-0.893) for the test cohort. Calibration curves showed strong agreement between predicted and observed outcomes, and decision curve analysis validated the model's utility for acute ASBO cases. CONCLUSION We developed and validated a CT-based nomogram that combines radiomic features with clinical data to predict the risk of surgical resection in ASBO patients. This tool offers valuable support for treatment planning and decision-making in emergent situations.
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Affiliation(s)
- Zhibo Wang
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
- Department of General Surgery, Weifang People's hospital, Weifang, 261000, China
| | - Ling Zhu
- Shandong Key Laboratory of Digital Medicine and Computer Assisted Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Shunli Liu
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Dalue Li
- Emergency Department, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Jingnong Liu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Xiaoming Zhou
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Yuxi Wang
- Acute Abdomen Surgery Department, The second hospital of Dalian medical university, Dalian, 116027, China
| | - Ruiqing Liu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China.
- The Affiliated Hospital of Qingdao University, Wutaishan-road No.1677, Qingdao, 266071, Shandong, China.
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Desiato E, Lucia AMA, Giudici S, Ammirabile A, Francone M, Lanza E, Del Fabbro D. Prognostic value of CT findings for conservative treatment failure in adhesive small bowel obstruction. Emerg Radiol 2025; 32:33-40. [PMID: 39073730 DOI: 10.1007/s10140-024-02276-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 07/19/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE This study aimed to identify the radiological CT findings that are significantly correlated with the outcome of conservative management with oral water-soluble contrast medium in patients presenting with Adhesive Small Bowel Obstruction (ASBO) to the Emergency Room. METHODS In this retrospective single-center study, we considered all consecutive patients admitted to the ER from February 2019 to February 2023 for ASBO with an available contrast-enhanced CT scan performed at diagnosis and treated with conservative management. The investigated CT findings were type and location of transition zone, ASBO degree, fat notch sign, beak sign, small bowel feces sign, presence of peritoneal free fluid and pneumatosis intestinalis. Radiological parameters were analyzed using univariable and multivariable logistic regression to test the significant association between the CT parameters and the target. RESULTS Among the 106 included patients (median age 74.5 years), conservative treatment was effective in 59 (55.7%) and failed in 47 (44.3%), needing delayed surgery. In the failure group, there was a higher prevalence of patients who had previous ASBO episodes (p = 0.03), a greater proportion of females (p = 0.04) and a longer hospital stay (p < 0.001). At multivariable analysis, two CT findings were significantly correlated with failure of conservative treatment: fat notch sign (OR = 2.95; p = 0.04) and beak sign (OR = 3.42; p = 0.04). CONCLUSIONS Two radiological signs correlate with failure of non-operative management in ASBO, suggesting their importance in surgical decision-making. Patients presenting with these signs are at higher risk of unsuccessful conservative treatment and may require undelayed surgical intervention.
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Affiliation(s)
- Elena Desiato
- Department of Biomedical Science, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, 20090, Italy
- Department of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy
| | - Ada Maria Antonella Lucia
- Department of Biomedical Science, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, 20090, Italy
| | - Simone Giudici
- Department of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy
| | - Angela Ammirabile
- Department of Biomedical Science, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, 20090, Italy.
- Department of Diagnostic and Interventional Radiology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy.
| | - Marco Francone
- Department of Biomedical Science, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, 20090, Italy
- Department of Diagnostic and Interventional Radiology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy
| | - Ezio Lanza
- Department of Biomedical Science, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, 20090, Italy
- Department of Diagnostic and Interventional Radiology, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy
| | - Daniele Del Fabbro
- Department of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan, 20089, Italy
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Berman DJ, Mahler AW, Burke RC, Bennett AE, Shapiro NI, Bilello LA. Associations of the Need for Surgery in Emergency Department Patients with Small Bowel Obstructions. West J Emerg Med 2025; 26:135-141. [PMID: 39918153 PMCID: PMC11908511 DOI: 10.5811/westjem.18455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 03/05/2024] [Accepted: 03/11/2024] [Indexed: 03/17/2025] Open
Abstract
Objectives Management strategies for small bowel obstruction (SBO) vary from conservative approaches to surgical intervention. A known complication of surgery is the subsequent adhesions that can cause recurrent SBOs, longer hospital stays, and higher treatment costs. Our primary outcome was to identify independent risk factors that are associated with the decision for surgical intervention, and our secondary outcome was to describe characteristics of visits associated with complications. Methods This study was a single-center, retrospective chart review from a large, urban university hospital. We included adult patients admitted to the emergency department (ED) with the International Classification of Diseases, 10th Rev, codes for small bowel obstruction from June 1, 2017- May 30, 2019. Eligible covariates were demographics, radiological findings, clinical presentation, past medical history, and results of radiologic testing. We identified univariate associations of outcome and then performed a multivariate logistic regression to identify independent associations of each outcome. Finally, a backwards selection was used to determine the final model. We calculated odds ratios (OR) and 95% confidence intervals (CI) along with the area under the curve (AUC), as appropriate. Results A total of 530 patients met the study criteria; 148 (27.9%) underwent surgery of whom 35 (6.6%) had complications. We identified seven independent associations for the decision of surgery: abdominal distension (OR 0.27, 95% CI 0.10-0.62); gastrografin (OR 0.41, 95% CI 0.20-0.81); previous SBO (OR 0.42, 95% CI 0.26-0.66); higher Charlson Comorbidity Index score (OR 0.87, 95% CI 0.80-0.95); nasogastric decompression (OR 2.04, 95% CI 1.25-3.39), initial systolic blood pressure <100 mm Hg (OR 2.65, 95% CI 1.05-6.53); free fluid or volvulus/closed-loop obstruction on computed tomography (OR 7.95, 95% CI 4.25-15.39), with the AUC for the predictive model equaling 0.73. Conclusion We identified seven independent associations present in the ED associated with the decision for surgery. These associations are a step toward building better prediction models and improving decision-making in the ED, allowing for a more adequate treatment plan.
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Affiliation(s)
- Daniel J Berman
- University of Southern Denmark, Odense, Denmark
- Co-first authors
| | - Alexander W Mahler
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
- Co-first authors
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Al-wageeh S, Alyhari Q, Ahmed F, Mohammed H, Dahan N, Almohtadi AM, AL-Nuzili STS, Badheeb M, Naji A. Clinical and Radiological Factors Associated with Nonoperative Management Failure for Small Bowel Obstruction: A Retrospective Study from a Resource-Limited Setting. Ther Clin Risk Manag 2024; 20:893-906. [PMID: 39734746 PMCID: PMC11682671 DOI: 10.2147/tcrm.s496629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2024] [Accepted: 12/20/2024] [Indexed: 12/31/2024] Open
Abstract
Background Recognizing factors that predict non-operative management (NOM) failure for patients with small bowel obstruction (SBO) aids in limiting surgical intervention when needed. This study investigated the predictive factors for NOM failure in SBO patients in a resource-limited setting. Material and Method A retrospective study included 165 patients who were diagnosed with SBO and were admitted and managed at Althora General Hospital, IBB, Yemen, from April 2022 to March 2024. Patients' baseline characteristics and profiles along with factors associated with failure of NOM were investigated and analyzed with univariate and multivariate analysis. Results 51 (30.4%) of included cohorts were managed non-operatively. The mean age was 47.7±16.9 years, and males were disproportionally presented (62.7%). The majority of patients presented with abdominal pain (96.1%). Failure of NOM was seen in 18 (35.3%) patients and intra-operative findings were adhesive bands, volvulus, intussusception, and mesenteric ischemia in 7 (38.9%), 5 (27.8%), 4 (22.2%), and 2 (11.1%) patients, respectively. Bowel resection was performed in 11 (61.1%), and 4 of them needed a colostomy diversion. Postoperative complications occurred in 13 (25.5%) patients, including fever, paralytic ileus, surgical site infection, and reoperation in 13 (25.5%), 5 (9.8%), 4 (7.8%), and 2 (3.9%) patients, respectively. Sixteen patients were discharged, and two patients died due to mesenteric ischemia. Among NOM successful patients, recurrence has occurred in 8 patients. In multivariate analysis, poor bowel wall enhancement (OR: 8.59; 95% CI: 1.14-64.59, p=0.037) and high level of obstruction (OR: 11.64; 95% CI: 1.34-100.85, p=0.026) in computed tomography (CT) scan were independently associated with NOM failure. Conclusion Poor bowel wall enhancement and significant obstruction on CT images are critical indicators for selecting SBO patients requiring urgent surgery. However, evaluating the advantages of surgical intervention versus NOM demands a comprehensive analysis of surgical risks, comorbidities, and the presence of bowel strangulation or ischemia.
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Affiliation(s)
- Saleh Al-wageeh
- Department of General Surgery, School of Medicine, Ibb University, Ibb, Yemen
| | - Qasem Alyhari
- Department of General Surgery, School of Medicine, Ibb University, Ibb, Yemen
| | - Faisal Ahmed
- Department of Urology, School of Medicine, Ibb University, Ibb, Yemen
| | - Hanan Mohammed
- Department of General Surgery, School of Medicine, Ibb University, Ibb, Yemen
| | - Noha Dahan
- Department of General Surgery, School of Medicine, Ibb University, Ibb, Yemen
| | | | | | - Mohamed Badheeb
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT, USA
| | - Abdulsattar Naji
- Department of General Surgery, School of Medicine, Ibb University, Ibb, Yemen
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Mazzotta AD, Burti E, Causio FA, Orlandi A, Martinelli S, Longaroni M, Pinciroli T, Debs T, Costa G, Miccini M, Aurello P, Petrucciani N. Machine Learning Approaches for the Prediction of Postoperative Major Complications in Patients Undergoing Surgery for Bowel Obstruction. J Pers Med 2024; 14:1043. [PMID: 39452550 PMCID: PMC11508771 DOI: 10.3390/jpm14101043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 09/13/2024] [Accepted: 09/25/2024] [Indexed: 10/26/2024] Open
Abstract
BACKGROUND Performing emergency surgery for bowel obstruction continues to place a significant strain on the healthcare system. Conventional assessment methods for outcomes in bowel obstruction cases often concentrate on isolated factors, and the evaluation of results for individuals with bowel obstruction remains poorly studied. This study aimed to examine the risk factors associated with major postoperative complications. METHODS We retrospectively analyzed 99 patients undergoing surgery from 2015 to 2022. We divided the patients into two groups: (1) benign-related obstruction (n = 68) and (2) cancer-related obstruction (n = 31). We used logistic regression, KNN, and XGBOOST. We calculated the receiver operating characteristic curve and accuracy of the model. RESULTS Colon obstructions were more frequent in the cancer group (p = 0.005). Operative time, intestinal resection, and stoma were significantly more frequent in the cancer group. Major complications were at 41% for the cancer group vs. 20% in the benign group (p = 0.03). Uni- and multivariate analysis showed that the significant risk factors for major complications were cancer-related obstruction and CRP. The best model was KNN, with an accuracy of 0.82. CONCLUSIONS Colonic obstruction is associated with tumor-related blockage. Malignant cancer and an increase in C-reactive protein (CRP) are significant risk factors for patients who have undergone emergency surgery due to major complications. KNN could improve the process of counseling and the perioperative management of patients with intestinal obstruction in emergency settings.
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Affiliation(s)
- Alessandro D. Mazzotta
- Department of Surgery, Vannini General Hospital, Oncological and General Surgery, 00177 Rome, Italy;
- The BioRobotics Institute, Sant’Anna School of Advanced Studies, 56127 Pisa, Italy
| | - Elisa Burti
- Department of Medical and Surgical Sciences and Translational Medicine, Division of General and Hepatobiliary Surgery, St. Andrea Hospital, Sapienza University of Rome, 00185 Roma, Italy; (E.B.); (P.A.); (N.P.)
| | - Francesco Andrea Causio
- Section of Hygiene, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Alex Orlandi
- EIT Digital Master School, Polytech Nice Sophia, 06410 Biot, France;
| | - Silvia Martinelli
- Section of Hygiene, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Mattia Longaroni
- Department of Surgery, Santa Maria della Misericordia Hospital, University of Perugia, 06123 Perugia, Italy;
| | - Tiziana Pinciroli
- MIT Professional Education, Massachusetts Institute of Technology, Cambridge, MA 02139, USA;
| | - Tarek Debs
- Département de Chirurgie Digestive, Centre Hospitalier Universitaire de Nice, CHU Nice, 06000 Nice, France;
| | - Gianluca Costa
- Department of Life Science, Health, and Health Professions, Link Campus University, 00165 Rome, Italy;
| | | | - Paolo Aurello
- Department of Medical and Surgical Sciences and Translational Medicine, Division of General and Hepatobiliary Surgery, St. Andrea Hospital, Sapienza University of Rome, 00185 Roma, Italy; (E.B.); (P.A.); (N.P.)
| | - Niccolò Petrucciani
- Department of Medical and Surgical Sciences and Translational Medicine, Division of General and Hepatobiliary Surgery, St. Andrea Hospital, Sapienza University of Rome, 00185 Roma, Italy; (E.B.); (P.A.); (N.P.)
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Shokoohi H, Al Jalbout N, Peksa GD, Mayes KD, Becker BA, Boniface KS, Lahham S, Secko M, Chavoshzadeh M, Jang T, Gottlieb M. Optimal bowel diameter thresholds for diagnosing small bowel obstruction and surgical intervention with point-of-care ultrasound. Am J Emerg Med 2024; 84:1-6. [PMID: 39043061 DOI: 10.1016/j.ajem.2024.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 07/25/2024] Open
Abstract
OBJECTIVES A bowel diameter threshold of ≥2.5 cm, originally derived from the research using computed tomography, is frequently used for diagnosing small bowel obstruction (SBO) with point-of-care ultrasound (POCUS). We sought to determine the optimal bowel diameter threshold for diagnosing SBO using POCUS and its accuracy in predicting surgical intervention. METHODS We conducted a secondary analysis using individual patient-level data from a previous systematic review on POCUS for SBO diagnosis across five academic EDs. Patient data were collected, including imaging results, surgical findings, and final diagnosis. The measured diameter of the small bowel using POCUS was recorded. ROC area under the receiver operating characteristic curves (AUC) were constructed to determine the optimal threshold for bowel diameter in predicting SBO diagnosis and surgical intervention. Subgroup analyses were performed based on sex and age. RESULTS A total of 403 patients had individual patient-level data available, with 367 patients included in the final analysis. The most accurate bowel diameter overall for predicting SBO was 2.75 cm (AUC = 0.76, 95% CI 0.71-0.81). A bowel diameter of ≤1.7 cm had 100% sensitivity with no miss rate, while a bowel diameter of ≥4 cm had 90.7% specificity in confirming SBO. Patients under 65 had an optimal threshold of 2.75 cm versus 2.95 cm in patients over 65. Females had an optimal threshold of 2.75 cm, while males had a value of 2.95 cm. There was no significant correlation between bowel diameter thresholds and surgical intervention. CONCLUSION A bowel diameter threshold of 2.75 cm on POCUS is more discriminative diagnostic accuracy for diagnosing SBO. Patients' age and sex may impact diagnostic accuracy, suggesting that tailored approaches may be needed.
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Affiliation(s)
- Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Nour Al Jalbout
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Gary D Peksa
- Rush University Medical Center, Chicago, IL, United States of America.
| | - Katherine Dickerson Mayes
- Harvard Affiliated Emergency Medicine Residency, Harvard Medical School, Boston, MA, United States of America.
| | - Brent A Becker
- Department of Emergency Medicine, WellSpan York Hospital, York, PA, United States of America
| | - Keith S Boniface
- Department of Emergency Medicine, George Washington University, Washington, DC, United States of America
| | - Shadi Lahham
- Department of Emergency Medicine, University of California at Irvine, Orange, CA, United States of America.
| | - Michael Secko
- Renaissance School of Medicine, Stony Brook University Hospital, Stony Brook, NY, United States of America.
| | | | - Timothy Jang
- Department of Emergency Medicine, Harbor UCLA, CA, United States of America.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
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Becnel M, Danner I, Santos MDL, Escobedo LJ, Mohrbacher M, Young J, Patterson R. The utility of a CT grading scale in deciding on surgical intervention for patients with suspected small bowel obstruction. Surg Open Sci 2024; 20:70-76. [PMID: 38946861 PMCID: PMC11214169 DOI: 10.1016/j.sopen.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/09/2024] [Accepted: 05/24/2024] [Indexed: 07/02/2024] Open
Abstract
Background A grading system was developed for computerized tomography (CT) scans evaluating patients with suspected small bowel obstruction (SBO). We hypothesized that patients with a higher grade of suspected SBO on CT scan would be more likely to require surgical intervention. Methods Retrospective chart review of patients who presented to the Emergency Room (ER) who had a CT of the abdomen and pelvis for suspected SBO. Patients were divided into 5 groups: Grade 1 (SBO unlikely), Grade 2 (probable partial or early SBO), Grade 3 (probable high grade SBO), Grade 4 (SBO with changes concerning for ischemia) and Not Graded. Results The CT scans of 655 patients were graded. Of the 22 patients with a grade 1 SBO, only 1 went for surgery (4.5 %). For grade 2 patients, 23 out of 299 had an operation (7.7 %), for grade 3 it was 84 out of 299 (28.1 %) and for grade 4 SBO, 25 out of 35 patients (71.4 %) had surgery. The p value is <0.00001. The three most common intraoperative findings were SBO obstruction from adhesions alone (48 % of cases), followed by incarcerated hernias (12 %) and ischemic bowel (9 %). Only 8 cases out of 133 operations (6 % of total) had no findings at time of surgery other than dilated bowel. Conclusions The CT grading scale for SBO developed at our institution shows excellent correlation between grade and going for surgery, with few negative results, and can be a useful tool among other factors for general surgeons when deciding whether or not to operate on a patient with suspected SBO.
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Affiliation(s)
- Marianne Becnel
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Ikaikaolahui Danner
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Maria De Los Santos
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Lindsay J. Escobedo
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Marie Mohrbacher
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Jacob Young
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Robert Patterson
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
- Intermountain Health American Fork Hospital, 170 N 1100 E, American Fork, UT 84043, USA
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10
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Eze VN, Parry T, Boone D, Mallett S, Halligan S. Prognostic factors to identify resolution of small bowel obstruction without need for operative management: systematic review. Eur Radiol 2024; 34:3861-3871. [PMID: 37938387 PMCID: PMC11166786 DOI: 10.1007/s00330-023-10421-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/06/2023] [Accepted: 09/24/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVES To identify imaging, clinical, and laboratory variables potentially prognostic for surgical management of small bowel obstruction. METHODS Two researchers systematically reviewed indexed literature 2001-2021 inclusive for imaging, clinical, and laboratory variables potentially predictive of surgical management of small bowl obstruction and/or ischaemia at surgery, where performed. Risk of bias was assessed. Contingency tables for variables reported in at least 5 studies were extracted and meta-analysed to identify strong evidence of association with clinical outcomes, across studies. RESULTS Thirty-one studies were ultimately included, reporting 4638 patients (44 to 313 per study). 11 (35%) studies raised no risk of bias concerns. CT was the modality reported most (29 studies, 94%). Meta-analysis of 21 predictors identified 5 strongly associated with surgical intervention, 3 derived from CT (peritoneal free fluid, odds ratio [OR] 3.24, 95%CI 2.45 to 4.29; high grade obstruction, OR 3.58, 95%CI 2.46 to 5.20; mesenteric inflammation, OR 2.61, 95%CI 1.94 to 3.50; abdominal distension, OR 2.43, 95%CI 1.34 to 4.42; peritonism, OR 3.97, 95%CI 2.67 to 5.90) and one with conservative management (previous abdominopelvic surgery, OR 0.58, 95%CI 0.40 to 0.85). Meta-analysis of 10 predictors identified 3 strongly associated with ischaemia at surgery, 2 derived from CT (peritoneal free fluid, OR 3.49, 95%CI 2.28 to 5.35; bowel thickening, OR 3.26 95%CI 1.91 to 5.55; white cell count, OR 4.76, 95%CI 2.71 to 8.36). CONCLUSIONS Systematic review of patients with small bowel obstruction identified four imaging, three clinical, and one laboratory predictors associated strongly with surgical intervention and/or ischaemia at surgery. CLINICAL RELEVANCE STATEMENT Via systematic review and meta-analysis, we identified imaging, clinical, and laboratory predictors strongly associated with surgical management of small bowel obstruction and/or ischaemia. Multivariable model development to guide management should incorporate these since they display strong evidence of potential utility. KEY POINTS • While multivariable models incorporating clinical, laboratory, and imaging factors could predict surgical management of small bowel obstruction, none are used widely. • Via systematic review and meta-analysis we identified imaging, clinical, and laboratory variables strongly associated with surgical management and/or ischaemia at surgery. • Development of multivariable models to guide management should incorporate these predictors, notably CT scanning, since they display strong evidence of potential utility.
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Affiliation(s)
- Vivienne N Eze
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Tom Parry
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Darren Boone
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK.
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11
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Talwar G, McKechnie T, Lee Y, Kazi T, El-Sayes A, Bogach J, Hong D, Eskicioglu C. Modified frailty index predicts postoperative morbidity in adhesive small bowel obstruction: analyzing the National Inpatient Sample 2015-2019. J Gastrointest Surg 2024; 28:205-214. [PMID: 38445910 DOI: 10.1016/j.gassur.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/08/2023] [Accepted: 10/25/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND There are limited data identifying predictors of postoperative outcomes in adhesive small bowel obstruction (ASBO). This study used the National Inpatient Sample (NIS) to assess the efficacy of the modified frailty index (mFI) to predict postoperative morbidity among patients undergoing an operation for ASBO. METHODS A retrospective analysis of the NIS between September 1, 2015, and December 31, 2019, was performed to identify adult patients who underwent nonelective operative intervention for ASBO. The mFI was used to stratify patients as either frail (mFI value ≥ 0.27) or robust (mFI value < 0.27). The primary outcomes were overall in-hospital postoperative morbidity and mortality. The secondary outcomes were system-specific morbidity, length of stay (LOS), total in-hospital healthcare cost, and discharge disposition. Univariable and multivariable regressions were used. RESULTS Overall, 23251 robust patients and 6122 frail patients were included. Adjusted analyses demonstrated that frail patients had increased in-hospital mortality (adjusted odds ratio [aOR], 2.16; 95% CI, 1.80-2.60), postoperative morbidity (aOR, 1.63; 95% CI, 1.52-1.74), postoperative LOS (adjusted mean difference [aMD], 0.97 days; 95% CI, 0.73-1.21), and total in-hospital healthcare costs (aMD, $18,921; 95% CI, $14,608-$23,235) and were less likely to be discharged home (aOR, 0.59; 95% CI, 0.55-0.63). The findings were unchanged on subgroup analysis of patients undergoing open operation and those older than 65 years of age. CONCLUSION The mFI may predict postoperative outcomes for ASBO. Stratifying patients based on frailty may assist clinicians and patients in making informed decisions, setting realistic expectations, and proactively planning postoperative disposition.
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Affiliation(s)
- Gaurav Talwar
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tania Kazi
- Faculty of Health Sciences Undergraduate Medical Education, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Abdullah El-Sayes
- Faculty of Health Sciences Undergraduate Medical Education, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Bogach
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
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12
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Matsuda K, Hashiguchi Y, Hayama T, Hayashi K, Miyata T, Asako K, Fukushima Y, Shimada R, Kaneko K, Nozawa K, Ochiai H, Yamamoto T. Laparoscopy-Assisted Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis in Middle Colic Artery Ligation Immediately before Specimen Removal. Inflamm Intest Dis 2024; 9:55-61. [PMID: 38529083 PMCID: PMC10963053 DOI: 10.1159/000538025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 02/19/2024] [Indexed: 03/27/2024] Open
Abstract
Introduction Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical procedure for ulcerative colitis (UC). Intestinal ischemia may occur if the main blood vessels are ligated at an early stage of this surgery. Considering that the blood flow in the large intestine can be maintained by preserving the middle colic artery, we have used a new IPAA method: ligating the middle colic artery immediately before removal of the specimens ("M-method"). Here, we evaluated the M-method's clinical outcomes. Methods Between April 2009 and December 2021, 13 patients underwent a laparoscopy-assisted IPAA procedure at our institution. The conventional method was used for 6 patients, and the M-method was used for the other 7 patients. We retrospectively analyzed the cases' clinical notes. Results The M-method's rate of postoperative complications (Clavien-Dindo classification grade II or more) was significantly lower than that of the conventional method (14.2% vs. 83.3%). The M-method group's postoperative stay period was also significantly shorter (average 16.4 days vs. 55.5). There were significant differences in the albumin value and the ratio of the modified GPS score 1 or 2 on the 7th postoperative day between the M- and conventional methods (average 3.15 vs. 2.5, average 4/7 vs. 6/6). However, it is necessary to consider the small number of cases and the uncontrolled historical comparison. Conclusion Late ligation of the middle colic artery may be beneficial for patients' post-surgery recovery and can be recommended for IPAAs in UC patients.
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Affiliation(s)
- Keiji Matsuda
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yojiro Hashiguchi
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Tamuro Hayama
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Kurara Hayashi
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Toshiya Miyata
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Kentaro Asako
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | | | - Ryu Shimada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Kensuke Kaneko
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Keijiro Nozawa
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Hiroki Ochiai
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takatsugu Yamamoto
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
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13
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Al‐Tarakji M, Almogtaba M, Al‐Hashimy Y, Moustafa OS, Shehata MS, Al‐Zoubi RM, Ghali MS. Laparoscopic management of intestinal obstruction in a young adult with a virgin abdomen: Unusual presentation of combined vitellointestinal duct remnants: A clinical case report. Clin Case Rep 2024; 12:e8395. [PMID: 38239756 PMCID: PMC10794868 DOI: 10.1002/ccr3.8395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/22/2024] Open
Abstract
Key Clinical Message In an 18-year-old, Meckel's diverticulum and a rare vitellointestinal fibrous band caused bowel obstruction. Clinicians should be vigilant for such anomalies, especially in young adults with virgin abdomens, as potential sources of intestinal obstruction. Abstract In this case report, we highlight the rarity of vitellointestinal or omphalomesenteric duct anomalies causing intestinal obstruction in the adult population. The patient, an 18-year-old male, presented to the emergency department with a two-day history of abdominal pain and vomiting. Physical examination revealed mild distension of his virgin abdomen with generalized tenderness. Abdominal X-ray displayed dilated small bowel loops, and a computed tomography scan indicated features consistent with closed-loop bowel obstruction. Diagnostic laparoscopy confirmed a vitellointestinal duct remnant as the cause of the small intestinal obstruction, involving a combined Meckel's diverticulum and vitellointestinal fibrous band. In early fetal development, the vitellointestinal duct communicates between the midgut and the yolk sac, expected to disappear during fetal growth. Failure to obliterate can lead to issues such as intestinal blockage, primarily observed in children, making occurrences in adults, as in this case, infrequent with only a few documented instances. Despite its uncommon occurrence in young adults, healthcare providers should consider the vitellointestinal duct anomalous remnant as a potential source of intestinal obstruction, particularly in individuals with a virgin abdomen. Early detection of intestinal obstruction is imperative for patient survival, facilitating prompt management and minimizing the risk of serious morbidities, ultimately contributing to a better patient outcome.
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Affiliation(s)
| | - Mohamed Almogtaba
- Department of Surgery, Acute Care SurgeryHamad Medical CorporationDohaQatar
| | - Yaseen Al‐Hashimy
- Department of Surgery, Acute Care SurgeryHamad Medical CorporationDohaQatar
| | - Omar S. Moustafa
- Department of Surgery, General SurgeryHamad Medical CorporationDohaQatar
| | - Mona S. Shehata
- Department of Pharmacy, Woman's Wellness and Research CenterHamad Medical CorporationDohaQatar
| | - Raed M. Al‐Zoubi
- Surgical Research Section, Department of SurgeryHamad Medical CorporationDohaQatar
- Department of Biomedical Sciences, QU‐Health, College of Health SciencesQatar UniversityDohaQatar
| | - Mohamed Said Ghali
- Department of Surgery, Acute Care SurgeryHamad Medical CorporationDohaQatar
- Department of General SurgeryAin Shams UniversityCairoEgypt
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14
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Ghabisha S, Ahmed F, Altam A, Hassan F, Badheeb M. Small Bowel Obstruction in Virgin Abdomen: Predictors of Surgical Intervention Need in Resource-Limited Setting. J Multidiscip Healthc 2023; 16:4003-4014. [PMID: 38107087 PMCID: PMC10725698 DOI: 10.2147/jmdh.s441958] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023] Open
Abstract
Background Limited evidence is available regarding the management of small bowel obstruction in the virgin abdomen (SBO-VA), with most studies excluding this entity. This study aims to assess the available data on the treatment outcomes and predictors of surgical intervention in SBO-VA. Methods A retrospective cross-sectional study was conducted between 2015 and 2021, including all diagnosed and managed cases of SBO-VA at Al-Nasar Hospital. Patients were divided according to the treatment approach into surgical or conservative groups. Preoperative laboratory and radiologic data were gathered and compared between groups. Results During the study period, 67 cases, primarily males (58.2%), with an average age of 52.2±14.4 years were assessed. Common comorbidities included diabetes (20.9%) and hypertension (16.4%). Key symptoms were rebound tenderness (82.1%) and abdominal tenderness (70.1%). The predominant etiology was adhesions (23.9%). About 46.2% received conservative treatment, 53.8% underwent urgent surgery. Conservative treatment failed in 9.4% of cases, and complications arose in 23.9%, with most being fever (17.9%). Factors necessitating surgical management included older age (58.8 ±11.7 vs 44.9 ±13.8 years, p<0.001), previous hospital admission (p<0.001), presence of abdominal tenderness (p=0.030), longer abdominal pain duration (4.0 ±0.9 vs 2.1 ±0.6 days, p<0.001), higher C- reactive protein (p= 0.033), higher white blood cell (p= 0.006), longer time to hospital presentation (75.3 ±17.2 vs 39.0 ±22.8 days, p= <0.001), small bowel thickness ≥3 cm (p=0.009), and reduced bowel enhancement (p <0.001) on computed tomography imaging. In surgical group, the need for ICU admission was higher and hospital stays were shorter than in conservative group and were statistically significant (p<0.05). Conclusion The main etiology of SBO-VA in our study was adhesions. Older age, previous hospital admission, longer abdominal pain duration, abdominal tenderness, increased inflammatory markers, and alarm signs on CT scans are the main factors for determining the need for urgent surgical exploration in patients with SBO-VA. To achieve prompt identification and intervention, it is crucial to maintain a high level of vigilance and awareness, even in individuals with no prior surgical history.
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Affiliation(s)
- Saif Ghabisha
- Department of General Surgery, School of Medicine, Ibb University, Ibb, Yemen
| | - Faisal Ahmed
- Department of Urology, School of Medicine, Ibb University, Ibb, Yemen
| | - Abdulfattah Altam
- Department of General Surgery, School of Medicine, 21 September University, Sana’a, Yemen
| | - Fouad Hassan
- Department of Nutrition and Dietetics, School of Medicine, Ibb University, Ibb, Yemen
| | - Mohamed Badheeb
- Department of Internal Medicine, Yale New-Haven Health/Bridgeport Hospital, Bridgeport, CT, USA
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15
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Yu W, Zhang Q, Ali M, Chen B, Yang Y, Wang L, Sun Q, Wang Y, Wang D. A nomogram for predicting the recurrence of small bowel obstruction after gastrectomy in patients with gastric cancer. World J Surg Oncol 2023; 21:351. [PMID: 37946228 PMCID: PMC10633924 DOI: 10.1186/s12957-023-03197-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/19/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND This study aimed to create a nomogram for predicting the recurrence of small bowel obstruction (SBO) after gastrectomy in patients with gastric cancer (GC) in order to provide better guidance for its diagnosis and treatment. METHODS A total of 173 patients undergone gastrectomy and developed SBO from January 2015 to October 2022 were admitted into this case-control study. The risk factors of postoperative recurrent SBO were analyzed by univariate and multivariate regression, and a nomogram for predicting the recurrent SBO after gastrectomy was developed using R Studio. RESULTS Thirty-nine cases of postoperative recurrent SBO occurred among the 173 GC patients who underwent radical gastrectomy, and the percentage of recurrent SBO was 22.54% (39/173). Age [odds ratio (OR) = 0.938, p = 0.026], WBC count (OR = 1.547, p < 0.001), tumor size (OR = 1.383, p = 0.024), postoperative metastasis (OR = 11.792, p = 0.030), and the interval from gastrectomy to first SBO (OR = 1.057, p < 0.001) were all identified as independent risk factors for postoperative recurrent SBO by logistic regression analysis. The receiver operating characteristic curve, the calibration curve, the model consistency index, and the decision curve analysis showed that the nomogram had good predictive performance. CONCLUSION Based on these factors, we created a nomogram to predict the occurrence of postoperative recurrent SBO. This novel nomogram could serve as a crucial early warning indicator that would guide doctors to make informed decisions while managing patients with gastric cancer.
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Grants
- No. 81972269 the National Natural Science Foundation of China
- No. 81972269 the National Natural Science Foundation of China
- No. 81972269 the National Natural Science Foundation of China
- No. 81972269 the National Natural Science Foundation of China
- No. 81972269 the National Natural Science Foundation of China
- No. 81972269 the National Natural Science Foundation of China
- No. 81972269 the National Natural Science Foundation of China
- No. 81972269 the National Natural Science Foundation of China
- No. 81972269 the National Natural Science Foundation of China
- No. YZ2020159 Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
- No. YZ2020159 Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
- No. YZ2020159 Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
- No. YZ2020159 Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
- No. YZ2020159 Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
- No. YZ2020159 Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
- No. YZ2020159 Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
- No. YZ2020159 Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
- No. YZ2020159 Key Laboratory of Basic and Clinical Transformation of Digestive and Metabolic Diseases, Yangzhou, China
- No. Bk20221144 the Natural Science Foundation of Jiangsu Province
- No. Bk20221144 the Natural Science Foundation of Jiangsu Province
- No. Bk20221144 the Natural Science Foundation of Jiangsu Province
- No. Bk20221144 the Natural Science Foundation of Jiangsu Province
- No. Bk20221144 the Natural Science Foundation of Jiangsu Province
- No. Bk20221144 the Natural Science Foundation of Jiangsu Province
- No. Bk20221144 the Natural Science Foundation of Jiangsu Province
- No. Bk20221144 the Natural Science Foundation of Jiangsu Province
- No. Bk20221144 the Natural Science Foundation of Jiangsu Province
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Affiliation(s)
- Wenhao Yu
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu Province, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Medical College of Yangzhou University, Yangzhou, China
| | - Qi Zhang
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu Province, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Medical College of Yangzhou University, Yangzhou, China
| | - Muhammad Ali
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu Province, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Medical College of Yangzhou University, Yangzhou, China
| | - Bangquan Chen
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu Province, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Medical College of Yangzhou University, Yangzhou, China
| | - Yapeng Yang
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu Province, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
- Medical College of Yangzhou University, Yangzhou, China
| | - Liuhua Wang
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu Province, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
| | - Qiannan Sun
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu Province, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
| | - Yong Wang
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu Province, China
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China
| | - Daorong Wang
- Department of Gastrointestinal Surgery, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No.98 Nantong West Road, Yangzhou, Jiangsu Province, China.
- General Surgery Institute of Yangzhou, Yangzhou University, Yangzhou, China.
- Medical College of Yangzhou University, Yangzhou, China.
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16
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van Veen T, Ramanathan P, Ramsey L, Dort J, Tabello D. Predictive factors for operative intervention and ideal length of non-operative trial in adhesive small bowel obstruction. Surg Endosc 2023; 37:8628-8635. [PMID: 37495847 DOI: 10.1007/s00464-023-10282-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 07/05/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Small bowel obstruction (SBO) is responsible for 350,000 U.S. hospitalizations and costs ~ $2.3 billion annually. The current standard of care for SBO is to trial 3 to 5 days of non-operative management. This study evaluated the factors associated with operative management. METHODS This retrospective cohort study included adult patients admitted with adhesive SBO. Exclusions were for operative intervention within 24 h or death. RESULTS At baseline (N = 360), mean age was 65.9 years, 57.8% female, 72.3% white, mean BMI 26.1, 38.7% with history of SBO and 98.1% had history of abdominal surgery. Symptom onset prior to hospitalization was 1-2 days. 55.6% had successful non-operative management at discharge (median length of stay 3 days) vs. 44.4% operative conversion. In univariate analyses, BMI, SBO history, surgical history, days symptom onset, vitals, abdominal pain, obstipation, acute kidney injury, and lack of small bowel feces sign on CT scan were significantly associated with operative management. In a multivariable logistic regression, after controlling all other variables, a lack of small bowel feces sign (adjusted odds ratio, aOR = 2.25, 95% CI 1.06-4.77, p = 0.04) and history of exploratory laparotomy (aOR = 0.44, 95% CI 0.21-0.90, p = 0.03) were significantly associated with operative management. Time from admission to surgery averaged 3.89 days: small bowel resection (55/160) was 4.9 days (median = 4), compared to patients without resection (3.4 days, median = 2; p = 0.00; OR = 1.2, 95% CI 1.07-1.35). CONCLUSIONS A lack of small bowel feces sign can be a potential indicator for operative management and should be further explored. Since the median resolution of symptoms in the non-operative management group was ~ 2 days and a 20% higher odds for bowel resection each day surgery is delayed, the conservative trial period for adhesive SBO should not exceed 3 days.
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Affiliation(s)
- Tara van Veen
- Department of Surgery, Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA, 22042, USA.
| | | | - Lolita Ramsey
- Department of Surgery, Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Jonathan Dort
- Department of Surgery, Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Dina Tabello
- Department of Surgery, Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA, 22042, USA
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Reintam Blaser A, Starkopf J, Björck M, Forbes A, Kase K, Kiisk E, Laisaar KT, Mihnovits V, Murruste M, Mändul M, Voomets AL, Tamme K. Diagnostic accuracy of biomarkers to detect acute mesenteric ischaemia in adult patients: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:44. [PMID: 37658356 PMCID: PMC10474684 DOI: 10.1186/s13017-023-00512-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/20/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Acute mesenteric ischaemia (AMI) is a disease with different pathophysiological mechanisms, leading to a life-threatening condition that is difficult to diagnose based solely on clinical signs. Despite widely acknowledged need for biomarkers in diagnosis of AMI, a broad systematic review on all studied biomarkers in different types of AMI is currently lacking. The aim of this study was to estimate the diagnostic accuracy of all potential biomarkers of AMI studied in humans. METHODS A systematic literature search in PubMed, The Cochrane Library, Web of Science and Scopus was conducted in December 2022. Studies assessing potential biomarkers of AMI in (at least 10) adult patients and reporting their diagnostic accuracy were included. Meta-analyses of biomarkers' sensitivity, specificity, and positive and negative likelihood ratios were conducted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study quality was assessed with the QUADAS-2 tool. RESULTS Seventy-five studies including a total of 9914 patients assessed 18 different biomarkers in serum/plasma and one in urine (each reported in at least two studies), which were included in meta-analyses. None of the biomarkers reached a conclusive level for accurate prediction. The best predictive value overall (all studies with any type and stage of AMI pooled) was observed for Ischaemia-modified albumin (2 studies, sensitivity 94.7 and specificity 90.5), interleukin-6 (n = 4, 96.3 and 82.6), procalcitonin (n = 6, 80.1 and 86.7), and intestinal fatty acid-binding protein (I-FABP) measured in serum (n = 16, 73.9 and 90.5) or in urine (n = 4, 87.9 and 78.9). In assessment of transmural mesenteric ischaemia, urinary I-FABP (n = 2, 92.3 and 85.2) and D-dimer (n = 3, 87.6 and 83.6) showed moderate predictive value. Overall risk of bias was high, mainly because of selected study populations and unclear timings of the biomarker measurements after onset of symptoms. Combinations of biomarkers were rarely studied, not allowing meta-analyses. CONCLUSIONS None of the studied biomarkers had sufficient sensitivity and specificity to diagnose AMI, although some biomarkers showed moderate predictive accuracy. Future studies should focus on timing of measurements of biomarkers, distinguishing between early stage and transmural necrosis, and between different types of AMI. Additionally, studies on combinations of biomarkers are warranted. PROSPERO registration: CRD42022379341.
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Affiliation(s)
- Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia.
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Joel Starkopf
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Martin Björck
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
| | - Karri Kase
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Ele Kiisk
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Kaja-Triin Laisaar
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Vladislav Mihnovits
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Marko Murruste
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Merli Mändul
- Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Anna-Liisa Voomets
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Kadri Tamme
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
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Sobocki J, Pędziwiatr M, Bigda J, Hołówko W, Major P, Mitura K, Myśliwiec P, Nowosad M, Obcowska-Hamerska A, Orłowski M, Proczko-Stepaniak M, Szeliga J, Wallner G, Zawadzki M. The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part II. Wideochir Inne Tech Maloinwazyjne 2023; 18:379-400. [PMID: 37868279 PMCID: PMC10585467 DOI: 10.5114/wiitm.2023.127884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/27/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method. Aim The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions. Material and methods The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. The recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method. Results and conclusions There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The second part of the guidelines covers sections 6 to12 and the following challenges for surgical practice: acute appendicitis, acute mesenteric ischemia, abdominal injuries, bowel obstruction, diverticulitis, laparoscopy in pregnancy and postoperative complications requiring a reoperation.
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Affiliation(s)
- Jacek Sobocki
- Chair and Department of General Surgery and Clinical Nutrition, Medical Center of Postgraduate Education Warsaw, Warsaw, Poland
| | - Michał Pędziwiatr
- 2 Department of General Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - Justyna Bigda
- Department of General, Endocrine and Transplant Surgery, University Medical Center, Medical University of Gdansk, Gdansk, Poland
| | - Wacław Hołówko
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Major
- 2 Department of General Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - Kryspin Mitura
- Faculty of Medical and Health Sciences, Siedlce University of Natural Sciences and Humanities, Siedlce, Poland
| | - Piotr Myśliwiec
- 1 Department of General and Endocrine Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Małgorzata Nowosad
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Aneta Obcowska-Hamerska
- Department of General, Vascular and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Michał Orłowski
- Department of General and Oncological Surgery, Florian Ceynowa Specialist Hospital, Wejherowo, Poland
| | - Monika Proczko-Stepaniak
- Department of General, Endocrine and Transplant Surgery, University Medical Center, Medical University of Gdansk, Gdansk, Poland
| | - Jacek Szeliga
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum of the Nicolaus Copernicus University, Torun, Poland
| | - Grzegorz Wallner
- 2 Department and Clinic of General, Gastroenterological and Cancer of the Digestive System Surgery, Medical University of Lublin, Lublin, Poland
| | - Marek Zawadzki
- Department of Oncological Surgery, Provincial Specialist Hospital, Wroclaw, Poland
| | - the Expert Group: Prof. Tomasz Banasiewicz, Prof. Andrzej Budzyński, Prof. Adam Dziki, Prof. Michał Grąt, Prof. Marek Jackowski, Prof. Wojciech Kielan, Prof. Andrzej Matyja, Prof. Krzysztof Paśnik, Prof. Piotr Richter, Prof. Antoni Szczepanik, Prof. Mirosław Szura, Prof. Wiesław Tarnowski, Prof. Krzysztof Zieniewicz
- Chair and Department of General Surgery and Clinical Nutrition, Medical Center of Postgraduate Education Warsaw, Warsaw, Poland
- 2 Department of General Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland
- Department of General, Endocrine and Transplant Surgery, University Medical Center, Medical University of Gdansk, Gdansk, Poland
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
- Faculty of Medical and Health Sciences, Siedlce University of Natural Sciences and Humanities, Siedlce, Poland
- 1 Department of General and Endocrine Surgery, Medical University of Bialystok, Bialystok, Poland
- Department of General, Vascular and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
- Department of General and Oncological Surgery, Florian Ceynowa Specialist Hospital, Wejherowo, Poland
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum of the Nicolaus Copernicus University, Torun, Poland
- 2 Department and Clinic of General, Gastroenterological and Cancer of the Digestive System Surgery, Medical University of Lublin, Lublin, Poland
- Department of Oncological Surgery, Provincial Specialist Hospital, Wroclaw, Poland
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Ng ZQ, Hsu V, Tee WWH, Tan JH, Wijesuriya R. Predictors for success of non-operative management of adhesive small bowel obstruction. World J Gastrointest Surg 2023; 15:1116-1124. [PMID: 37405103 PMCID: PMC10315117 DOI: 10.4240/wjgs.v15.i6.1116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/21/2023] [Accepted: 04/13/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Majority of adhesive small bowel obstruction (SBO) cases can be managed non-operatively. However, a proportion of patients failed non-operative management.
AIM To evaluate the predictors of successful non-operative management in adhesive SBO.
METHODS A retrospective study was performed for all consecutive cases of adhesive SBO from November 2015 to May 2018. Data collated included basic demographics, clinical presentation, biochemistry and imaging results and management outcomes. The imaging studies were independently analyzed by a radiologist who was blinded to the clinical outcomes. The patients were divided into group A operative (including those that failed initial non-operative management) and group B non-operative for analysis.
RESULTS Of 252 patients were included in the final analysis; group A (n = 90) (35.7%) and group B (n = 162) (64.3%). There were no differences in the clinical features between both groups. Laboratory tests of inflammatory markers and lactate levels were similar in both groups. From the imaging findings, the presence of a definitive transition point [odds ratio (OR) = 2.67, 95% confidence interval (CI): 0.98-7.32, P = 0.048], presence of free fluid (OR = 2.11, 95%CI: 1.15-3.89, P = 0.015) and absence of small bowel faecal signs (OR = 1.70, 95%CI: 1.01-2.88, P = 0.047) were predictive of the need of surgical intervention. In patients that received water soluble contrast medium, the evidence of contrast in colon was 3.83 times predictive of successful non-operative management (95%CI: 1.79-8.21, P = 0.001).
CONCLUSION The computed tomography findings can assist clinicians in deciding early surgical intervention in adhesive SBO cases that are unlikely to be successful with non-operative management to prevent associated morbidity and mortality.
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Affiliation(s)
- Zi Qin Ng
- Department of General Surgery, St John of God Midland Hospital, Midland 6056, Western Australia, Australia
| | - Vivien Hsu
- Department of General Surgery, St John of God Midland Hospital, Midland 6056, Western Australia, Australia
| | - William Wei Han Tee
- Department of Radiology, St John of God Midland Hospital, Midland 6056, Western Australia, Australia
| | - Jih Huei Tan
- Department of General Surgery, Hospital Sultanah Aminah, Johor Bahru 80000, Johor, Malaysia
| | - Ruwan Wijesuriya
- Department of General Surgery, St John of God Midland Hospital, Midland 6056, Western Australia, Australia
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20
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Liu X, Zhu M, Wu M, Cheng Z, Wu X, Zhu R. Unenhanced CT-based predictive model to identify small bowel necrosis in patients with mechanical small bowel obstruction. BMC Med Imaging 2023; 23:80. [PMID: 37308879 DOI: 10.1186/s12880-023-01041-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/05/2023] [Indexed: 06/14/2023] Open
Abstract
OBJECTIVES To investigate the diagnostic value of unenhanced CT in mechanical small bowel obstruction (SBO) with small bowel necrosis, and to establish a predictive model. METHODS From May 2017 to December 2021, the patients with mechanical SBO admitted to our hospital were retrospectively collected. Taking pathology-confirmed small bowel necrosis as the gold standard, the experimental group was composed of patients with small bowel necrosis confirmed by pathology, and the control group was composed of patients with no intestinal necrosis confirmed by surgery or successful conservative treatment with no recurrence of intestinal obstruction during 1-month followed-up. RESULTS A total of 182 patients were enrolled in this study, 157 patients underwent surgery, of which 35 patients were accompanied with small bowel necrosis and 122 patients were not (33 patients with ischemic findings at surgery without necrosis). Finally, there were 35 patients in the experimental group and 147 patients in the control group. Multivariable logistic regression showed that increased attenuation of small bowel wall (P = 0.002), diffuse mesenteric haziness (P = 0.010), difference of CT value between mesenteric vessel and aorta (P = 0.025) and U-/C-shaped small bowel loop (P = 0.010) were independent risk factors for the diagnosis of mechanical SBO with small bowel necrosis. Through internal verification, the area under curve (AUC) of the predictive model reached 0.886 (95%CI: 0.824-0.947), and the calibration result was moderate. CONCLUSION Multiple features (increased attenuation of small bowel wall; difference of CT values between mesenteric vessel and aorta; diffuse mesenteric haziness; and U-/C-shaped small bowel loop) of unenhanced CT have clinical value in the diagnosis of mechanical SBO with small bowel necrosis. The predictive model based on these four features could achieve satisfactory efficiency.
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Affiliation(s)
- Xianwei Liu
- Department of General Surgery, Jiujiang No.1 People's Hospital, Jiangxi province, Jiujiang, Jiujiang, China.
| | - MingJie Zhu
- Department of Gastrointestinal Surgery, The People's Hospital of Leshan, Sichuan province, Leshan, China
| | - Ming Wu
- Department of Image Center, Jiujiang No.1 People's Hospital, Jiangxi province, Jiujiang, China
| | - Zhangsong Cheng
- Department of Image Center, Jiujiang No.1 People's Hospital, Jiangxi province, Jiujiang, China
| | - Xiaoyu Wu
- Department of General Surgery, Jiujiang No.1 People's Hospital, Jiangxi province, Jiujiang, Jiujiang, China
| | - Renfang Zhu
- Department of General Surgery, Jiujiang No.1 People's Hospital, Jiangxi province, Jiujiang, Jiujiang, China
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21
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Kim HR, Lee Y, Kim J, Baek TW, Kim H, Son JH, Park EJ, Kim SH. Closed loop obstruction of small bowel: CT signs predicting successful non-surgical treatment. Eur J Radiol 2023; 161:110716. [PMID: 36758277 DOI: 10.1016/j.ejrad.2023.110716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/04/2022] [Accepted: 01/24/2023] [Indexed: 01/29/2023]
Abstract
PURPOSE To clarify the computed tomography (CT) findings related to successful conservative treatments in patients with closed-loop small bowel obstruction (CL-SBO) without evidence of bowel strangulation. METHODS Sixty-four patients (71 CT scans) diagnosed with CL-SBO by CT and received initial conservative treatments from May 2010 to August 2020 were retrospectively included. Two blinded radiologists reviewed the CT findings, including the transition zone (number, distance, and location), maximum bowel diameter, mesenteric haziness, mesenteric fluid, increased unenhanced bowel wall attenuation, decreased bowel wall enhancement, small bowel feces sign, whirl sign, bowel wall thickening, ascites, and degree of obstruction. The findings of the success and failure groups of conservative treatment were compared. Interobserver agreement was assessed for all findings. RESULTS Among the 71 cases, conservative treatments were successful in 42 cases (59 %) but failed in 29 cases (41 %). In multivariable analyses, the distance between the transition zones (>1 cm) and low-degree obstruction were independently associated with successful conservative treatments, with odds ratios of 6.23 and 3.52, respectively. The combination of these two CT findings exhibited a specificity of 89.7 % with a positive likelihood ratio of 3.01. Interobserver agreement of the degree of obstruction and the distance between the transition zones was almost perfect (ĸ = 0.814 and 0.914, respectively). CONCLUSIONS The distance between the transition zones (>1 cm) and low-grade obstruction are independent CT predictors of successful conservative treatments in CL-SBO patients. Initial conservative treatments are recommended for patients with both CT findings.
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Affiliation(s)
- Hye Ri Kim
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Yedaun Lee
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea.
| | - Jieun Kim
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Tae Wook Baek
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Hyunwoong Kim
- Clinical Trial Center, Inje University College of Medicine, Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Jung Hee Son
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Eun Joo Park
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
| | - Seung Ho Kim
- Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan 48108, Republic of Korea
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Xu WX, Zhong QH, Cai Y, Zhan CH, Chen S, Wang H, Tu PS, Chen WX, Chen XQ, Zhang JR. Comprehensively evaluate the short outcome of small bowel obstruction: A novel medical-economic score system. World J Gastroenterol 2023; 29:1509-1522. [PMID: 36998422 PMCID: PMC10044851 DOI: 10.3748/wjg.v29.i9.1509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/01/2023] [Accepted: 02/15/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Small bowel obstruction (SBO) still imposes a substantial burden on the health care system. Traditional evaluation systems for SBO outcomes only focus on a single element. The comprehensive evaluation of outcomes for patients with SBO remains poorly studied. Early intensive clinical care would effectively improve the short-term outcomes for SBO, however, the full spectrum of the potential risk status regarding the high complication-cost burden is undetermined.
AIM We aim to construct a novel system for the evaluation of SBO outcomes and the identification of potential risk status.
METHODS Patients who were diagnosed with SBO were enrolled and stratified into the simple SBO (SiBO) group and the strangulated SBO (StBO) group. A principal component (PC) analysis was applied for data simplification and the extraction of patient characteristics, followed by separation of the high PC score group and the low PC score group. We identified independent risk status on admission via a binary logistic regression and then constructed predictive models for worsened management outcomes. Receiver operating characteristic curves were drawn, and the areas under the curve (AUCs) were calculated to assess the effectiveness of the predictive models.
RESULTS Of the 281 patients, 45 patients (16.0%) were found to have StBO, whereas 236 patients (84.0%) had SiBO. Regarding standardized length of stay (LOS), total hospital cost and the presence of severe adverse events (SAEs), a novel principal component was extracted (PC score = 0.429 × LOS + 0.444 × total hospital cost + 0.291 × SAE). In the multivariate analysis, risk statuses related to poor results for SiBO patients, including a low lymphocyte to monocyte ratio (OR = 0.656), radiological features of a lack of small bowel feces signs (OR = 0.316) and mural thickening (OR = 1.338), were identified as risk factors. For the StBO group, higher BUN levels (OR = 1.478) and lower lymphocytes levels (OR = 0.071) were observed. The AUCs of the predictive models for poor outcomes were 0.715 (95%CI: 0.635-0.795) and 0.874 (95%CI: 0.762-0.986) for SiBO and StBO stratification, respectively.
CONCLUSION The novel PC indicator provided a comprehensive scoring system for evaluating SBO outcomes on the foundation of complication-cost burden. According to the relative risk factors, early tailored intervention would improve the short-term outcomes.
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Affiliation(s)
- Wei-Xuan Xu
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350122, Fujian Province, China
| | - Qi-Hong Zhong
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350122, Fujian Province, China
| | - Yong Cai
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350122, Fujian Province, China
| | - Can-Hong Zhan
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350122, Fujian Province, China
| | - Shuai Chen
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Hui Wang
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Peng-Sheng Tu
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Wen-Xuan Chen
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Xian-Qiang Chen
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
| | - Jun-Rong Zhang
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
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23
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Economic Consequences of Surgery for Adhesive Small Bowel Obstruction: A Population-Based Study. Gastroenterol Res Pract 2023; 2023:1844690. [PMID: 36879620 PMCID: PMC9985498 DOI: 10.1155/2023/1844690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/02/2023] [Accepted: 02/10/2023] [Indexed: 03/08/2023] Open
Abstract
Background and Aims Most patients develop adhesions after abdominal surgery, some will be hospitalized with small bowel obstruction (SBO), and some also require surgery. The operations and follow-up are expensive, but recent data of costs are scarce. The aim of this study was to describe the direct costs of SBO-surgery and follow-up, in a population-based setting. The association between cost of SBO and peri- and postoperative data was also studied. Methods In a retrospective cohort study, all patients (n = 402) operated for adhesive SBO in Gävleborg and Uppsala counties (2007-2012) were studied. The median follow-up was 8 years. Costs were calculated according to the pricelist of Uppsala University Hospital, Uppsala, Sweden. Results Overall total costs were €16.267 million, corresponding to a mean total cost per patient of €40,467 during the studied period. Diffuse adhesions and postoperative complications were associated with increased costs for SBO in a multivariable analysis (P < 0.001). Most costs, about €14 million (85%), arouse in conjunction with the SBO-index surgery period. In-hospital stay was the dominating cost, accounting for 70% of the total costs. Conclusion Surgery for SBO generates substantial economic burden for healthcare systems. Measures that reduce the incidence of SBO, the frequency of postoperative complication, or the length of stay have the potential to reduce this economic burden. The cost estimates from this study may be valuable for future cost-benefit analyses in intervention studies.
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Diagnostic nomogram for closed-loop small bowel obstruction requiring emergency surgery. Am J Emerg Med 2023; 63:5-11. [PMID: 36283292 DOI: 10.1016/j.ajem.2022.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/30/2022] [Accepted: 10/11/2022] [Indexed: 12/07/2022] Open
Abstract
PURPOSE This study aimed to build a diagnostic model of closed-loop small bowel obstruction (CL-SBO) using clinical information, blood test results, and computed tomography (CT) findings. METHODS All patients who were diagnosed with small bowel obstruction (SBO) and underwent surgery between January 1, 2018, and October 31, 2021, in the affiliated hospital of Qingdao university were reviewed, and their relevant preoperative information was collected. All variables were selected using univariate analysis and backward stepwise regression to build a diagnostic nomogram model. K-fold cross-validation and bootstrap resampling techniques were used for internal validation, and data from Qingdao Central Hospital were used for external validation. We also evaluated the diagnostic performance of each CT finding and performed subgroup analysis according to bowel ischemia in the closed-loop small bowel obstruction (CL-SBO) group. RESULTS A total of 219 patients (95 in the CL-SBO group and 124 in the open-loop small bowel obstruction [OL-SBO] group) were included in our research. D-dimers (median 1085 vs. 690, P = 0.019), tenderness (77.9% vs. 59.7%, P = 0.004), more than one beak sign (65.3% vs. 30.6%, P < 0.001), radial distribution (18.9% vs. 6.5%, P = 0.005), whirl sign (35.8% vs. 8.9%, P < 0.001), and ascites (71.6% vs. 53.2%, P = 0.006) were selected as the predictive variables of the nomogram. This model's Harrell's C statistic was 0.786 (95% confidence interval (CI), 0.724-0.848), and the Brier score was 0.182. The Harrell's C statistic of external validation was 0.784 (95%CI, 0.664-0.905); the Brier score was 0.190. Regarding the CT findings, radial distribution, U/C-shaped loop, and whirl sign had high specificity (93.5%, 96.0%, and 91.1%, respectively), but low sensitivity (18.9%, 8.4%, and 35.8%, respectively). D-dimer levels and tenderness were also associated with bowel ischemia. CONCLUSION The nomogram accurately predicted CL-SBO in patients with SBO, and surgery should be considered when patients have a high risk for developing CL-SBO.
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The value of MSCT in evaluating the passability of bezoar by conservative treatment for bezoars-induced small bowel obstruction. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:236-243. [PMID: 36242605 DOI: 10.1007/s00261-022-03700-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/28/2022] [Accepted: 09/28/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE To explore the multi-slice spiral computed tomography (MSCT) imaging characteristics of patients with bezoars-induced small bowel obstruction (BI-SBO) to evaluate the risk of conservative treatment. MATERIALS AND METHODS This retrospective study included 72 patients with BI-SBO who underwent whole-abdominal MSCT scan within 1 day before treatment. The patients were classified as the non-pass group and pass group depending on whether bezoar can pass after conservative treatment. The CT images were observed and measured by two radiologists. Statistical analysis was performed by using Student's t test, Pearson's chi-squared test, Fisher's exact test, Logistic linear regression, and receiver operating characteristic curve (ROC). RESULTS The study population consisted of 72 patients with a mean age of 52.2 ± 16.2 years (32 men and 40 women with an age range of 13-81 years). There were statistical differences between the two groups in the bezoar appearance, maximum HU of bezoar, thickness of intestinal wall, mesenteric haziness, mesenteric fluid, and peritoneal fluid (P = 0.002, 0.024, 0.017, 0.006, 0.021, and 0.030). The appearance of bezoar and mesenteric haziness is independent risk factors affecting whether bezoar can be passed by the conservative treatment. Sensitivity (41.7%) was decreased, NPV (76.3%) was not significantly changed, specificity (93.8%) and PPV (76.9%) were improved when both parameters were met to assess failure of conservative treatment. CONCLUSION The observation of important signs by MSCT and its reconstruction technology is of great clinical value in evaluating the passability of bezoar by conservative treatment, and which can provide radiographic basis for clinical treatment selection.
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Liu M, Cheng F, Liu X, Zheng B, Wang F, Qin C, Ding G, Fu T, Geng L. Diagnosis and surgical management strategy for pediatric small bowel obstruction: Experience from a single medical center. Front Surg 2023; 10:1043470. [PMID: 36896265 PMCID: PMC9989272 DOI: 10.3389/fsurg.2023.1043470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/30/2023] [Indexed: 02/23/2023] Open
Abstract
Identifying Bowel strangulation and the approach and timing of surgical intervention for pediatric SBO are still uncertain. In this study, 75 consecutive pediatric patients with surgically confirmed SBO were retrospectively reviewed. The patients were divided into group 1 (n = 48) and group 2 (n = 27) according to the presence of reversible or irreversible bowel ischemia, which was analyzed based on the degree of ischemia at the time of operation. The results demonstrated that the proportion of patients with no prior abdominopelvic surgery was higher, the serum albumin level was lower, and the proportion of patients in which ascites were detected by ultrasonography was higher in group 2 than that in group 1. The serum albumin level was negatively correlated with ultrasonographic findings of the fluid sonolucent area in group 2. There were significant differences in the choice of surgical approach between group 1 and group 2. A symptom duration of >48 h was associated with an increased bowel resection rate. The mean length of hospital stay was shorter in group 1 than that in group 2. In conclusion, immediate surgical intervention should be considered in patients with a symptom duration of >48 h or the presence of free ascites between dilated small bowel loops on ultrasonography. Laparoscopic exploration is recommended as first-line treatment in patients with stable status.
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Affiliation(s)
- Mingzhu Liu
- Binzhou Medical University Hospital, Binzhou, China
| | | | - Xijie Liu
- Binzhou Medical University Hospital, Binzhou, China
| | - Bufeng Zheng
- Binzhou Medical University Hospital, Binzhou, China
| | - Feifei Wang
- Binzhou Medical University Hospital, Binzhou, China
| | - Chengwei Qin
- Binzhou Medical University Hospital, Binzhou, China
| | - Guojian Ding
- Binzhou Medical University Hospital, Binzhou, China
| | - Tingliang Fu
- Binzhou Medical University Hospital, Binzhou, China
| | - Lei Geng
- Binzhou Medical University Hospital, Binzhou, China
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Uttinger K, Mehdorn M, Gockel I. [82/f-Abdominal pain and no defecation for 10 days : Preparation for the medical specialist examination: part 6]. CHIRURGIE (HEIDELBERG, GERMANY) 2022; 93:25-29. [PMID: 36066594 DOI: 10.1007/s00104-022-01719-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Konstantin Uttinger
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstraße 20, Haus 4, 04103, Leipzig, Deutschland
| | - Matthias Mehdorn
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstraße 20, Haus 4, 04103, Leipzig, Deutschland.
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, AöR, Liebigstraße 20, Haus 4, 04103, Leipzig, Deutschland
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Small Bowel Obstruction in Patients without Prior Abdominal Surgery: To Operate or Not? World J Surg 2022; 46:2919-2926. [PMID: 36059038 DOI: 10.1007/s00268-022-06719-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Surgical exploration is still considered mandatory in the setting of small bowel obstruction (SBO) in patients without prior intra-abdominal surgery. However, recent studies have challenged this 'classic' approach describing success with conservative non-surgical treatment. The aim of this study is to identify clinical, radiological and biochemical variables that may be associated with the absence of intra-abdominal pathology in patients with SBO who have not undergone previous surgery. METHODS This is a retrospective cohort study of prospectively recorded data. Patients with SBO without prior abdominal surgery who presented to a single tertiary referral medical center between 2009 and 2019 were included. RESULTS Eighty-seven patients were included of whom 61(70.0%) were allocated to the 'therapeutic exploration' group and 26 (30.0%) to the 'non-therapeutic exploration' group. Forty-eight patients (55.0%) had adhesions, 17.2% had closed-loop obstruction, 10.0% had an internal hernia, 27.6% had bowel ischemia and 5.7% had bowel necrosis. Although multiple clinical, laboratory, radiological and preoperative factors were examined, none were significantly associated with pathological findings during surgical exploration. There was no statistically significant difference in the incidence of complications when comparing between those groups. CONCLUSIONS In this series, no variables were associated with intra-abdominal pathology in patients who underwent surgery for SBO with no history of prior abdominal surgery. However, the fact that 27.0% had ischemic bowel upon surgical exploration suggests that this approach is still mandatory for this specific group of patients. Furthermore, clinicians and patients should be aware that negative exploration may be expected in up to 30.0%.
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Pavlidis ET, Pavlidis TE. Prediction factors for ischemia of closed-loop small intestinal obstruction. World J Gastrointest Surg 2022; 14:1086-1088. [PMID: 36185555 PMCID: PMC9521473 DOI: 10.4240/wjgs.v14.i9.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 02/07/2023] Open
Abstract
A closed-loop type of intestinal obstruction leads to ischemic necrosis. There have been indicators that may predict ischemia and its severity, such as biomarkers and computed tomography scans. In addition to the usual inflammation markers, such as white blood count-neutrophil count and c-reactive protein (CRP), the most accurate predictors that have been proposed are the CRP-to-albumin ratio, the neutrophil/lymphocyte ratio and the platelet/lymphocyte ratio. Endothelin 1 is another promising biomarker of ischemia that must be assessed in daily clinical practice. Advanced age and frailty status were assessed as predictors of mortality. A timely operative procedure without any delay ensures a better outcome.
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Affiliation(s)
- Efstathios Theodoros Pavlidis
- The Second Propedeutic Department of Surgery, Hippocration Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 54642, Greece
| | - Theodoros Efstathios Pavlidis
- The Second Propedeutic Department of Surgery, Hippocration Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 54642, Greece
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Does Amount of Intra-abdominal Fluid on CT May Predict Failure of Non-operative Management in Patients with Small Bowel Obstruction? Indian J Surg 2022. [DOI: 10.1007/s12262-021-03052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Rubalcava NS, Speck KE. Current Management of Adhesive Small Bowel Obstructions in Children. Adv Pediatr 2022; 69:243-257. [PMID: 35985714 DOI: 10.1016/j.yapd.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Adhesive small bowel obstructions are a common cause of morbidity in children who underwent prior abdominal surgery. The concept of partial versus complete bowel obstruction is outdated and lacks precision to be clinically useful. Identifying patients with indications for immediate operative intervention is critical and must be recognized to limit morbidity. Clinical protocols and contrast challenge algorithms have attempted to identify patients that will resolve their bowel obstruction nonoperatively; there has been slow uptake in the pediatric patient population versus adults until recently. Incorporating predictive models and standardized contrast challenge protocols will help reduce interpractitioner variability and improve clinical outcomes.
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Affiliation(s)
- Nathan S Rubalcava
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Mott Children's Hospital, 1540 East Hospital Drive SPC 4217, Ann Arbor, MI 48109-4217, USA; Department of Surgery, Creighton University Health Science Campus, 3100 North Central Avenue, Phoenix, AZ 85012, USA
| | - K Elizabeth Speck
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Mott Children's Hospital, 1540 East Hospital Drive SPC 4217, Ann Arbor, MI 48109-4217, USA.
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Toneman MK, de Kok BM, Zijta FM, Oei S, van Acker GJD, Westerterp M, van der Pool AEM. Predicting the outcome of closed-loop small bowel obstruction by preoperative characteristics. World J Gastrointest Surg 2022; 14:556-566. [PMID: 35979424 PMCID: PMC9258239 DOI: 10.4240/wjgs.v14.i6.556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/24/2021] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Closed-loop small bowel obstruction (CL-SBO) can threaten the viability of the intestine by obstructing a bowel segment at two adjacent points. Prompt recognition and surgery are crucial.
AIM To analyze the outcomes of patients who underwent surgery for CL-SBO and to evaluate clinical predictors.
METHODS Patients who underwent surgery for suspected CL-BSO on computed tomography (CT) at a single center between 2013 and 2019 were evaluated retrospectively. Patients were divided into three groups by perioperative outcome, including viable bowel, reversible ischemia, and irreversible ischemia. Clinical and laboratorial variables at presentation were compared and postoperative outcomes were analyzed.
RESULTS Of 148 patients with CL-SBO, 28 (19%) had a perioperative viable small bowel, 86 (58%) had reversible ischemia, and 34 (23%) had irreversible ischemia. Patients with a higher age had higher risk for perioperative irreversible ischemia [odds ratio (OR): 1.03, 95% confidence interval (CI): 0.99-1.06]. Patients with American Society of Anaesthesiologists (ASA) classification ≥ 3 had higher risk of perioperative irreversible ischemia compared to lower ASA classifications (OR: 3.76, 95%CI: 1.31-10.81). Eighty-six patients (58%) did not have elevated C-reactive protein (> 10 mg/L), and between-group differences were insignificant. Postoperative in-hospital stay was significantly longer for patients with irreversible ischemia (median 8 d, P = 0.001) than for those with reversible ischemia (median 6 d) or a viable bowel (median 5 d). Postoperative morbidity was significantly higher in patients with perioperative irreversible ischemia (45%, P = 0.043) compared with reversible ischemia (20%) and viable bowel (4%).
CONCLUSION Older patients or those with higher ASA classification had an increased risk of irreversible ischemia in case of CL-SBO. After irreversible ischemia, postoperative morbidity was increased.
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Affiliation(s)
- Masja K Toneman
- Department of Surgery, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
| | - Bente M de Kok
- Department of Radiology, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
| | - Frank M Zijta
- Department of Radiology, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
| | - Stanley Oei
- Department of Radiology, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
| | - Gijs J D van Acker
- Department of Surgery, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
| | - Marinke Westerterp
- Department of Surgery, Haaglanden Medical Centre, The Hague 2512 VA, Netherlands
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Xu WX, Zhong QH, Cai Y, Zhan CH, Chen S, Wang H, Lin L, Geng YQ, Hou P, Chen XQ, Zhang JR. Prediction and management of strangulated bowel obstruction: a multi-dimensional model analysis. BMC Gastroenterol 2022; 22:304. [PMID: 35733109 PMCID: PMC9219133 DOI: 10.1186/s12876-022-02363-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 05/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Distinguishing strangulated bowel obstruction (StBO) from simple bowel obstruction (SiBO) still poses a challenge for emergency surgeons. We aimed to construct a predictive model that could distinctly discriminate StBO from SiBO based on the degree of bowel ischemia. METHODS The patients diagnosed with intestinal obstruction were enrolled and divided into SiBO group and StBO group. Binary logistic regression was applied to identify independent risk factors, and then predictive models based on radiological and multi-dimensional models were constructed. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) were calculated to assess the accuracy of the predicted models. Via stratification analysis, we validated the multi-dimensional model in the prediction of transmural necrosis both in the training set and validation set. RESULTS Of the 281 patients with SBO, 45 (16.0%) were found to have StBO, while 236(84.0%) with SiBO. The AUC of the radiological model was 0.706 (95%CI, 0.617-0.795). In the multivariate analysis, seven risk factors including pain duration ≤ 3 days (OR = 3.775), rebound tenderness (OR = 5.201), low-to-absent bowel sounds (OR = 5.006), low levels of potassium (OR = 3.696) and sodium (OR = 3.753), high levels of BUN (OR = 4.349), high radiological score (OR = 11.264) were identified. The AUC of the multi-dimensional model was 0.857(95%CI, 0.793-0.920). In the stratification analysis, the proportion of patients with transmural necrosis was significantly greater in the high-risk group (24%) than in the medium-risk group (3%). No transmural necrosis was found in the low-risk group. The AUC of the validation set was 0.910 (95%CI, 0.843-0.976). None of patients in the low-risk and medium-risk score group suffered with StBO. However, all patients with bowel ischemia (12%) and necrosis (24%) were resorted into high-risk score group. CONCLUSION The novel multi-dimensional model offers a useful tool for predicting StBO. Clinical management could be performed according to the multivariate score.
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Affiliation(s)
- Wei-Xuan Xu
- Fujian Medical University, No.1 Xuefu bei Road, Fuzhou, 350122, Fujian Province, China
| | - Qi-Hong Zhong
- Fujian Medical University, No.1 Xuefu bei Road, Fuzhou, 350122, Fujian Province, China
| | - Yong Cai
- Fujian Medical University, No.1 Xuefu bei Road, Fuzhou, 350122, Fujian Province, China
| | - Can-Hong Zhan
- Fujian Medical University, No.1 Xuefu bei Road, Fuzhou, 350122, Fujian Province, China
| | - Shuai Chen
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - Hui Wang
- Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - Lin Lin
- Department of Radiology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - Ying-Qian Geng
- Department of Radiology, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
| | - Ping Hou
- Fujian Medical University, No.1 Xuefu bei Road, Fuzhou, 350122, Fujian Province, China.,Immunotherapy Institute, Fujian Medical University, No.1 Xuefu bei Road, Fuzhou, 350122, Fujian Province, China
| | - Xian-Qiang Chen
- Fujian Medical University, No.1 Xuefu bei Road, Fuzhou, 350122, Fujian Province, China. .,Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
| | - Jun-Rong Zhang
- Fujian Medical University, No.1 Xuefu bei Road, Fuzhou, 350122, Fujian Province, China. .,Department of General Surgery (Emergency Surgery), Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
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Maraux L, Dammaro C, Gaillard M, Lainas P, Derienne J, Maitre S, Chague P, Rocher L, Dagher I, Tranchart H. Predicting the Need for Surgery in Uncomplicated Adhesive Small Bowel Obstruction: A Scoring Tool. J Surg Res 2022; 279:33-41. [PMID: 35717794 DOI: 10.1016/j.jss.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 03/08/2022] [Accepted: 05/22/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Nonoperative treatment can be attempted for uncomplicated adhesive small bowel obstruction (ASBO), but carries a risk of delayed surgery. Highlighting initial parameters predicting risk of failure of nonoperative management would be of great interest. METHODS Patients initially managed conservatively for uncomplicated ASBO were retrospectively analyzed. Univariate and multivariate analysis were performed to identify predictive failure's factors. Based on the risk factors, a score was created and then prospectively validated in a different patients' population. RESULTS Among 171 patients included, 98 (57.3%) were successfully managed conservatively. In a multivariate analysis, three independent nonoperative management failure's factors were identified: Charlson Index ≥4 (P = 0.016), distal obstruction (P = 0.009), and maximum small bowel diameter over vertical abdominal diameter ratio >0.34 (P = 0.023). A score of two or three was associated with a risk of surgery of 51.4% or 70.3% in the retrospective analysis and 62.2% or 75% in the validation cohort, respectively. CONCLUSIONS This clinical-radiological score may help guide surgical decision-making in uncomplicated ASBO. A high score (≥2) was predictive of failure of nonoperative management. This tool could assist surgeons to determine who would benefit from early surgery.
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Affiliation(s)
- Lucien Maraux
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Carmelisa Dammaro
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Martin Gaillard
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Joseph Derienne
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Sophie Maitre
- Department of Radiology, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, Orsay, France
| | - Pierre Chague
- Department of Radiology, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, Orsay, France
| | - Laurence Rocher
- Department of Radiology, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, Orsay, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Hadrien Tranchart
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France.
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Yamamoto Y, Kitazawa M, Otsubo T, Miyagawa Y, Tokumaru S, Nakamura S, Koyama M, Ehara T, Hondo N, Iijima Y, Soejima Y. Comparison of Clinical Outcomes and Safety Between Open and Laparoscopic Surgery for Adhesive Small Bowel Obstruction: A Propensity-Matched Analysis of a National Inpatient Database. J Laparoendosc Adv Surg Tech A 2022; 32:1064-1070. [PMID: 35446138 DOI: 10.1089/lap.2022.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The effectiveness of laparoscopic surgery for adhesive small bowel obstruction (ASBO) remains unclear. We aimed to compare the outcomes and safety of open and laparoscopic surgeries for ASBO. Methods: In this retrospective study, we analyzed an inpatient database of 42 national university hospitals in Japan. Patients who underwent surgery for the first episode of ASBO between April 2013 and March 2018 were identified. Using the propensity score method, patients who underwent laparoscopic surgery were matched one-to-one with those who underwent open surgery. We investigated postoperative clinical outcomes, including morbidity, mortality, length of hospital stay (LOS), and recurrence. Results: Overall, 306 and 96 patients underwent open and laparoscopic surgery, respectively (96 propensity score-matched pairs). The incidence rates of postoperative morbidity, mortality, and recurrence were comparable between the two groups. Cox regression analysis revealed a hazard ratio (HR) of 1.020 (P = .959) for readmission due to ASBO in the laparoscopic surgery group relative to the open surgery group. Postoperative hospital stay was longer for open surgery than for laparoscopic surgery (13.0 days versus 10.0 days, P < .001). Cox regression analysis revealed that laparoscopic surgery was associated with earlier postoperative discharge compared with open surgery (HR 1.641, P = .002). Conclusions: The postoperative LOS was shorter with laparoscopic surgery than with open surgery for ASBO, but there were no differences between the procedures in other clinical outcomes. Laparoscopic surgery is suitable to treat patients with ASBO.
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Affiliation(s)
- Yuta Yamamoto
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Japan
| | - Masato Kitazawa
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Japan
| | - Tetsuya Otsubo
- The Database Center of the National University Hospitals, The University of Tokyo Hospital, Tokyo, Japan.,Division of Medical Information Technology and Administration Planning, Kyoto University Hospital, Kyoto, Japan
| | - Yusuke Miyagawa
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Japan
| | - Shigeo Tokumaru
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Japan
| | - Satoshi Nakamura
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Japan
| | - Makoto Koyama
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Japan
| | - Takehito Ehara
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Japan
| | - Nao Hondo
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Japan
| | - Yasuhiro Iijima
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Japan
| | - Yuji Soejima
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Asahi, Matsumoto, Japan
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Kyuno T, Otsuka K, Kobayashi M, Yoshida E, Sato K, Kawagishi R, Kono T, Chiba T, Kimura T, Yonezawa H, Funato O, Takagane A. Time limit to rescue intestine with viability at risk caused by blood flow disruption in patients presenting with acute abdomen. Surg Today 2022; 52:1627-1633. [PMID: 35338428 PMCID: PMC9592629 DOI: 10.1007/s00595-022-02495-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/27/2022] [Indexed: 11/24/2022]
Abstract
Purpose Early management is crucial for acute intestinal blood flow disorders; however, no published study has identified criteria for the time limit for blood flow resumption. This study specifically examines the time factors for avoiding intestinal resection. Methods The subjects of this retrospective cohort study were 125 consecutive patients who underwent emergency surgery for a confirmed diagnosis of intestinal strangulation (n = 86), incarceration (n = 27), or volvulus (n = 12), between January 2015 and March 2021. Intestinal resection was performed when intestinal irreversible changes had occurred even after ischemia was relieved surgically. We analyzed the relationship between the time from computed tomography (CT) imaging to the start of surgery (C-S time) and intestinal resection using the Kaplan–Meier method and calculated the estimated intestinal rescue rate. Patient background factors affecting intestinal resection were also examined. Results The time limit for achieving 80% intestinal rescue rate was 200 min in C-S time, and when this exceeded 300 min, the intestinal rescue rate dropped to less than 50%. Multivariate analysis identified the APACHE II score as a significant influencing factor. Conclusion A rapid transition from early diagnosis to early surgery is critical for patients with acute abdomen originating from intestinal blood flow disorders. The times from presentation at the hospital to surgery should be reduced further, especially for severe cases.
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Affiliation(s)
- Takuro Kyuno
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan.
| | - Kanki Otsuka
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan
| | - Makoto Kobayashi
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan
| | - Eiji Yoshida
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan
| | - Kei Sato
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan
| | - Ryoko Kawagishi
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan
| | - Tsuyoshi Kono
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan
| | - Takehiro Chiba
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan
| | - Toshimoto Kimura
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan
| | - Hitoshi Yonezawa
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan
| | - Osamu Funato
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan
| | - Akinori Takagane
- Department of Surgery, Hakodate Goryoukaku Hospital, 38-3, Goryoukaku-cho, Hakodate, Japan
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Machine Learning Based Prediction Model for Closed-Loop Small Bowel Obstruction Using Computed Tomography and Clinical Findings. J Comput Assist Tomogr 2022; 46:169-174. [PMID: 35297573 DOI: 10.1097/rct.0000000000001269] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of the study was to develop a prediction model for closed-loop small bowel obstruction integrating computed tomography (CT) and clinical findings. METHODS The radiology database and surgical reports from 2 suburban teaching hospitals were retrospectively reviewed for patients undergoing surgery for suspected closed-loop small bowel obstruction (CLSBO). Two observers independently reviewed the CT scans for the presence of imaging features of CLSBO, blinded to the surgically confirmed diagnosis and clinical parameters. Random forest analysis was used to train and validate a prediction model for CLSBO, by combining CT and clinical findings, after randomly splitting the sample into 80% training and 20% test subsets. RESULTS Surgery confirmed CLSBO in 185 of 223 patients with clinically suspected CLSBO. Age greater than 52 years showed 2.82 (95% confidence interval = 1.13-4.77) times higher risk for CLSBO (P = 0.021). Sensitivity/specificity of CT findings included proximal dilatation (97/5%), distal collapse (96/2%), mesenteric edema (94/5%), pneumatosis (1/100%), free air (1/98%), and portal venous gas (0/100%). The random forest model combining imaging/clinical findings yielded an area under receiver operating curve of 0.73 (95% confidence interval = 0.58-0.94), sensitivity of 0.72 (0.55-0.85), specificity of 0.8 (0.28-0.99), and accuracy of 0.73 (0.57-0.85). Prior surgery, age, lactate, whirl sign, U/C-shaped bowel configuration, and fecalization were the most important variables in predicting CLSBO. CONCLUSIONS A random forest model found clinical factors including prior surgery, age, lactate, and imaging factors including whirl sign, fecalization, and U/C-shaped bowel configuration are helpful in improving the prediction of CLSBO. Individual CT findings in CLSBO had either high sensitivity or specificity, suggesting that accurate diagnosis requires systematic assessment of all CT signs.
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Brower CH, Baugh CW, Shokoohi H, Liteplo AS, Duggan N, Havens J, Askari R, Rehani MM, Kapur T, Goldsmith AJ. Point-of-care ultrasound-first for the evaluation of small bowel obstruction: National cost savings, length of stay reduction, and preventable radiation exposure. Acad Emerg Med 2022; 29:824-834. [PMID: 35184354 DOI: 10.1111/acem.14464] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/31/2022] [Accepted: 02/16/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Computed tomography (CT) has long been the gold standard in diagnosing patients with suspected small bowel obstruction (SBO). Recently, point-of-care ultrasound (POCUS) has demonstrated comparable test characteristics to CT imaging for the diagnosis of SBO. Our primary objective was to estimate the annual national cost saving impact of a POCUS-first approach for the evaluation of SBO. Our secondary objectives were to estimate the reduction in radiation exposure and emergency department (ED) length of stay (LOS). METHODS We created and ran 1000 trials of a Monte Carlo simulation. The study population included all patients presenting to the ED with abdominal pain who were diagnosed with SBO. Using this simulation, we modeled the national annual cost savings in averted advanced imaging from a POCUS-first approach for SBO. The model assumes that all patients who require surgery or have non-diagnostic POCUS exams undergo CT imaging. The model also conservatively assumes that a subset of patients with diagnostic POCUS exams undergo additional confirmatory CT imaging. We used the same Monte Carlo model to estimate the reduction in radiation exposure and total ED bed hours saved. RESULTS A POCUS-first approach for diagnosing SBO was estimated to save a mean (±SD) of $30.1 million (±8.9 million) by avoiding 143,000 (±31,000) CT scans. This resulted in a national cumulative decrease of 507,000 bed hours (±268,000) in ED LOS. The reduction in radiation exposure to patients could potentially prevent 195 (±56) excess annual cancer cases and 98 (±28) excess annual cancer deaths. CONCLUSIONS If adopted widely and used consistently, a POCUS-first algorithm for SBO could yield substantial national cost savings by averting advanced imaging, decreasing ED LOS, and reducing unnecessary radiation exposure in patients. Clinical decision tools are needed to better identify which patients would most benefit from CT imaging for SBO in the ED.
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Affiliation(s)
- Charles H. Brower
- Department of Emergency Medicine University of Cincinnati Medical Center Cincinnati Ohio USA
| | - Christopher W. Baugh
- Department of Emergency Medicine, Harvard Medical School Brigham and Women's Hospital Boston Massachusetts United States
| | - Hamid Shokoohi
- Department of Emergency Medicine, Harvard Medical School Massachusetts General Hospital Boston Massachusetts USA
| | - Andrew S. Liteplo
- Department of Emergency Medicine, Harvard Medical School Massachusetts General Hospital Boston Massachusetts USA
| | - Nicole Duggan
- Department of Emergency Medicine, Harvard Medical School Brigham and Women's Hospital Boston Massachusetts United States
| | - Joaquim Havens
- Department of Surgery, Division of Trauma, Burn, and Surgical Critical Care, Harvard Medical School Brigham and Women's Hospital Boston Massachusetts USA
| | - Reza Askari
- Department of Surgery, Division of Trauma, Burn, and Surgical Critical Care, Harvard Medical School Brigham and Women's Hospital Boston Massachusetts USA
| | - Madan M. Rehani
- Department of Radiology Massachusetts General Hospital Boston Massachusetts USA
| | - Tina Kapur
- Department of Radiology, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
| | - Andrew J. Goldsmith
- Department of Emergency Medicine, Harvard Medical School Brigham and Women's Hospital Boston Massachusetts United States
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Lawrence EM, Pickhardt PJ. Evaluating suspected small bowel obstruction with the water-soluble contrast challenge. Br J Radiol 2022; 95:20210791. [PMID: 34826227 PMCID: PMC8822578 DOI: 10.1259/bjr.20210791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
With optimized technique, the water-soluble contrast challenge is effective at triaging patients for operative vs non-operative management of suspected small bowel obstruction. Standardized study structure and interpretation guidelines aid in clinical efficacy and ease of use. Many tips and tricks exist regarding technique and interpretation, and their understanding may assist the interpreting radiologist. In the future, a CT-based water-soluble contrast challenge, utilizing oral contrast given as part of the initial CT examination, might allow for a more streamlined algorithm and provide more rapid results.
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Affiliation(s)
- Edward M. Lawrence
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Perry J. Pickhardt
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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40
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Tyagunov AE, Sazhin AV, Tyagunov AA, Nechay TV, Ermakov IV. [Preoperative diagnosis of intestinal ischemia in small bowel obstruction. Only computed tomography? A multiple-center observational study]. Khirurgiia (Mosk) 2022:26-35. [PMID: 36562670 DOI: 10.17116/hirurgia202212226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the accuracy of clinical, laboratory and instrumental methods for diagnosis of intestinal ischemia following small bowel obstruction in emergency hospitals. MATERIAL AND METHODS Multiple-center observational retrospective study enrolled 158 consecutive patients with benign small bowel obstruction (SBO) treated at four hospitals between May 2017 and December 2019. The role of clinical, laboratory and instrumental diagnostic methods for intestinal ischemia was analyzed. We assessed the impact of CT and contrast-enhanced X-ray examination on survival of patients. RESULTS Laboratory parameters as criteria of ischemia following SBO were similar (leukocytosis >14·109/l (p=1.0), serum lactate >2.0 mmol/l (p=0.28), heart rate >90/min (p=0.71) and fever (p=0.74)). The only laboratory indicator with significant differences was serum sodium. Decrease in leukocytosis over time was less common in patients with ischemia (25% vs. 61.3%, p=0.012). Univariate Kaplan-Meier analysis did not establish the effect of CT on survival (7.8% [95% CI 7.6-8.0] vs. 6.5% [95% CI 6.3-6.6], p=0.786). Logistic regression revealed 6.4-fold higher chance of accurate diagnosis (ischemia/non-ischemia) in case of CT-based conclusion of ischemia (95% CI 0.025-0.85). Univariate analysis showed that the use of water-soluble contrast for adhesive SBO was associated with lower mortality (4.1% [95% CI 4.0-4.2] vs. 14.3% [95% CI 13.7-14.9], p=0.032) without assessing the comparability of groups. CONCLUSION Routine laboratory tests were not specific for intestinal ischemia. Therefore, they should not be considered as the only criteria for surgical tactics in intestinal obstruction. Only CT showed acceptable diagnostic accuracy, and, apparently, only this method has real prospects for improving the quality of diagnosis due to technical support, training of surgeons and specialists for diagnosis.
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Affiliation(s)
- A E Tyagunov
- Moscow Multidisciplinary Clinical Center "Kommunarka", Moscow, Russia
| | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Tyagunov
- Buyanov Municipal Clinical Hospital No. 12, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - I V Ermakov
- Pirogov Russian National Research Medical University, Moscow, Russia
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Tyagunov AE, Fedorov AV, Nechay TV, Tyagunov AA, Sazhin AV. [Surgical approach for small bowel obstruction in the Russian Federation. National survey of surgeons]. Khirurgiia (Mosk) 2022:5-17. [PMID: 35593623 DOI: 10.17116/hirurgia20220515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To study surgical approach for small bowel obstruction (SBO) regarding national and international guidelines. MATERIAL AND METHODS Considering literature data, national and international guidelines and clinical practice, we have formulated 15 questions regarding surgical approach for non-neoplastic SBO. Questions were sent by e-mail to the members of the Russian Society of Surgeons. Survey lasted 60 days. We used the program that provides the respondent with the possibility of visual control of survey results. Survey results were compared with national and international clinical guidelines, Russian- and English-language scientific publications. Restriction of the number of votes >1 and identification of respondents were not provided by the program. There was no reward for survey. A summary is provided on the main issues. RESULTS There were 557 respondents (3.0% of surgeons in the Russian Federation). We obtained 481-620 answers for each question. CONCLUSION This study is a valuable tool for primary assessment of current surgical practice for SBO in the Russian Federation. Study design did not imply conclusions on the optimal strategy based on opinions of majority of respondents. According to our survey, a significant number of respondents use the treatment strategy that differ from clinical guidelines. Their approach is based on their own clinical experience and local guidelines for the treatment of SBO. Less than half of the answers matched to national clinical guidelines, less than 10% - to the WSES guidelines. Despite the formal coincidence of some statements in national clinical guidelines and English-language recommendations, significant nonconformities require scientific discussion.
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Affiliation(s)
- A E Tyagunov
- Municipal Clinical Hospital No. 40, Moscow, Russia
| | - A V Fedorov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Tyagunov
- Buyanov Municipal Clinical Hospital No.12, Moscow, Russia
| | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
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Mahony CR, Traynor MD, Knight AW, Hughes JD, Hernandez MC, Finnesgard EJ, Musa J, Selby SL, Rivera M, Kim BD, Heller SF, Zielinski MD. Small bowel obstruction managed without hospital admission: A safe way to reduce both cost and time in the hospital? Surgery 2021; 171:1665-1670. [PMID: 34815095 DOI: 10.1016/j.surg.2021.10.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Small bowel obstruction management has evolved to incorporate the Gastrografin challenge. We expanded its use to the emergency department observation unit, potentially avoiding hospital admission for highly select small bowel obstruction patients. We hypothesized that the emergency department observation unit small bowel obstruction protocol would reduce admissions, costs, and the total time spent in the hospital without compromising outcomes. METHODS We reviewed patients who presented with small bowel obstruction from January 2015 to December 2018. Patients deemed to require urgent surgical intervention were admitted directly and excluded. The emergency department observation unit small bowel obstruction guidelines were introduced in November 2016. Patients were divided into pre and postintervention groups based on this date. The postintervention group was further subclassified to examine the emergency department observation unit patients. Cost analysis for each patient was performed looking at number of charges, direct costs, indirect cost, and total costs during their admission. RESULTS In total, 125 patients were included (mean age 69 ± 14.3 years). The preintervention group (n = 62) and postintervention group (n = 63) had no significant difference in demographics. The postintervention group had a 51% (36.7 hours, P < .001) reduction in median duration of stay and a total cost reduction of 49% (P < .001). The emergency department observation unit subgroup (n = 46) median length of stay was 23.6 hours. The readmission rate was 16% preintervention compared to 8% in the postintervention group (P = .18). CONCLUSION Management of highly selected small bowel obstruction patients with the emergency department observation unit small bowel obstruction protocol was associated with decreased length of stay and total cost, without an increase in complications, surgical intervention, or readmissions.
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Affiliation(s)
- Cillian R Mahony
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.
| | - Michael D Traynor
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Ariel W Knight
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Joy D Hughes
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Matthew C Hernandez
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Finnesgard
- Department of Vascular Surgery, University of Massachusetts Memorial Health Care, Worcester, MA
| | - Juna Musa
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Sasha L Selby
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Mariela Rivera
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Brian D Kim
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Stephanie F Heller
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Martin D Zielinski
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
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Correlation of CT findings with intra-operative outcome in closed-loop small bowel obstruction (CL-SBO). Eur J Radiol 2021; 142:109844. [PMID: 34252868 DOI: 10.1016/j.ejrad.2021.109844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/31/2021] [Accepted: 06/30/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To correlate CT-findings in patients with closed-loop small bowel obstruction (CL-SBO) with perioperative findings, to identify patients who require immediate surgical intervention. Secondary purpose was to substantiate the role of radiologists in predicting perioperative outcome. METHODS Data were retrospectively obtained from patients with surgically confirmed CL-SBO, between September 2013 and September 2019. Three radiologists reviewed CTs to assess defined CT features and predict patient outcome for bowel wall ischemia and necrosis using a likelihood score. Univariate statistical analyses were performed and diagnostic performance parameters and interobserver agreement were assessed for each feature. RESULTS Of 148 included patients, 28 (19%) intraoperatively had viable bowel and 120 (81%) had bowel wall ischemia or necrosis. Most CT characteristics, as well as the likelihood of ischemia and necrosis, found fair or moderate multirater agreement. Increased attenuation of bowel wall and mesenteric vessels on non-contrast-enhanced CT had a specificity for bowel ischemia or necrosis of 100% (sensitivity respectively 48% (p < 0.001) and 21% (p = 0.09)). Mesenteric edema had high sensitivity for ischemia or necrosis (90%), but specificity of only 26% (p < 0.001). For mesenteric fluid, sensitivity was 60% and specificity 57% (p = 0.004). Decreased enhancement of bowel wall in both arterial and PV-phase showed significant correlation, respectively a sensitivity of 58% and 42%, and specificity of 88% and 79% (both p < 0.001). Likelihood of both ischemia and necrosis were significantly correlated with perioperative outcome (p < 0.001). CONCLUSION CT findings concerning mesenteric and bowel wall changes, as well as radiologists' judgement of likelihood of ischemia and necrosis are significantly correlated with perioperative outcome of bowel wall ischemia and necrosis in patients with CL-SBO.
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Lebert P, Ernst O, Zins M, Lanchou M, Nzamushe JR, Vermersch M. Pneumatosis intestinalis and portal venous gas in mechanical small bowel obstruction: Is it worrisome? Diagn Interv Imaging 2021; 102:545-551. [PMID: 34030989 DOI: 10.1016/j.diii.2021.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical significance of pneumatosis intestinalis (PI) and portal venous gas (PVG) in patients with mechanical small bowel obstruction (SBO), using surgical findings or clinical follow-up as standard of reference. MATERIALS AND METHODS Fourteen patients with mechanical SBO associated with PI and PVG were retrospectively included. There were 7 men and 7 women with a mean age of 59±19 (SD) (range: 25-93 years). CT examinations were reviewed by two radiologists to confirm the diagnosis of mechanical SBO and make a description of PI. Interobserver agreement was calculated. The reference standard was intraoperative appearance of the bowel wall (10/14; 71%) or the recovery of a normal bowel function in patients who were managed conservatively (4/14; 29%). RESULTS Among the 10 patients who underwent surgery, a normal appearance of the bowel in association with PI on CT was found intraoperatively in 8/10 (80%) patients and a reversible ischemia in the remaining 2/10 (20%) patients. The four patients who were managed conservatively recovered normal bowel function. Two patients died within two weeks following SBO. CONCLUSION PI and PVG are not specific signs of bowel necrosis in mechanical SBO.
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Affiliation(s)
- Paul Lebert
- Department of Digestive Diagnostic and Interventional Radiology, Lille University Hospital, 59037 Lille Cedex, France.
| | - Olivier Ernst
- Department of Digestive Diagnostic and Interventional Radiology, Lille University Hospital, 59037 Lille Cedex, France
| | - Marc Zins
- Department of Radiology, Fondation Hôpital Saint-Joseph, 75014 Paris, France
| | - Marie Lanchou
- Department of Digestive Diagnostic and Interventional Radiology, Lille University Hospital, 59037 Lille Cedex, France
| | - Jean-Robert Nzamushe
- Department of Emergency Surgery, Lille University Hospital, 59037 Lille Cedex, France
| | - Mathilde Vermersch
- Department of Digestive Diagnostic and Interventional Radiology, Lille University Hospital, 59037 Lille Cedex, France
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Tyagunov AE, Tyagunov AA, Nechay TV, Vinogradov VN, Kurashinova LS, Sazhin AV. [Timing of surgery, intestinal ischemia and other real factors of mortality in acute adhesive small bowel obstruction: a multiple-center study]. Khirurgiia (Mosk) 2021:26-35. [PMID: 33710823 DOI: 10.17116/hirurgia202103126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To analyze the factors of mortality in patients with acute adhesive small bowel obstruction (AASBO). MATERIAL AND METHODS A retrospective multiple-center study included 143 (85.6%) patients with AASBO out of 167 consecutive patients with small bowel obstruction for the period 2017-2019. All patients were divided into 3 groups: early surgery group (within 12 hours after admission), late surgery (after 12 hours), non-surgical management group. The outcomes and Kaplan-Meier survival were compared in all groups. RESULTS AASBO was resolved without surgery in 77 (53.8%) patients 19.6±17.4 (M=14) hours. In the Early Surgery Group (n=36), 24 patients had strangulation, 12 ones had non-strangulated bowel obstruction. In the Late Surgery Group (n=30), 15 patients had strangulation and 15 ones had no strangulation. Mortality was similar in early and late surgery (p=0.287), early and late surgery in patients with strangulation (p=0.940), early and late surgery in patients without strangulation (p=0.76). Patients died (n=10) after surgery only. Thus, postoperative mortality was 15.2%, overall mortality - 7.0%. All patients who underwent surgery after 24 hours (n=14) survived. Surgery increased the mortality risk compared to non-surgical management (95% CI 0 - 15.9, p=0.001). There was no effect of surgery time (more or less than 12 hours) on mortality for strangulation (95% CI 13.0-16.7, p 0.788) and non-strangulated obstruction (95% CI 29.4-5.4, p=0.061), bowel resection (95% CI 33.3-14.0, p=0.187), presence of bowel ischemia (95% CI 14.3-17.9, p 0.613). CONCLUSION Delayed surgery may be advisable in patients with AASBO and no obvious signs of strangulation due to less mortality.
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Affiliation(s)
- A E Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Tyagunov
- Buyanov Municipal Clinical Hospital No 12, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - V N Vinogradov
- Pirogov Municipal Clinical Hospital No 1, Moscow, Russia
| | | | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
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Fitzpatrick LA, Rivers-Bowerman MD, Thipphavong S, Clarke SE, Rowe JA, Costa AF. Pearls, Pitfalls, and Conditions that Mimic Mesenteric Ischemia at CT. Radiographics 2021; 40:545-561. [PMID: 32125953 DOI: 10.1148/rg.2020190122] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate. The diagnosis of AMI is challenging because patient symptoms and laboratory test results are often nonspecific. A high degree of clinical and radiologic suspicion is required for accurate and timely diagnosis. CT angiography of the abdomen and pelvis is the first-line imaging test for suspected AMI and should be expedited. A systematic "inside-out" approach to interpreting CT angiographic images, beginning with the bowel lumen and proceeding outward to the bowel wall, mesentery, vasculature, and extraintestinal viscera, provides radiologists with a practical framework to improve detection and synthesis of imaging findings. The subtypes of AMI are arterial and venoocclusive disease, nonocclusive ischemia, and strangulating bowel obstruction; each may demonstrate specific imaging findings. Chronic mesenteric ischemia is more insidious at onset and almost always secondary to atherosclerosis. Potential pitfalls in the diagnosis of AMI include mistaking pneumatosis as a sign that is specific for AMI and not an imaging finding, misinterpretation of adynamic ileus as a benign finding, and pseudopneumatosis. Several enterocolitides can mimic AMI at CT angiography, such as inflammatory bowel disease, infections, angioedema, and radiation-induced enterocolitis. Awareness of pitfalls, conditions that mimic AMI, and potential distinguishing clinical and imaging features can assist radiologists in making an early and accurate diagnosis of AMI. ©RSNA, 2020.
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Affiliation(s)
- Laura A Fitzpatrick
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Michael D Rivers-Bowerman
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Seng Thipphavong
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Sharon E Clarke
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Judy A Rowe
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Andreu F Costa
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
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Ferris B, Bastian-Jordan M, Fenwick J, Hislop-Jambrich J. Vascular assessment in small bowel obstruction: can CT predict requirement for surgical intervention? Abdom Radiol (NY) 2021; 46:517-525. [PMID: 32770400 DOI: 10.1007/s00261-020-02698-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/24/2020] [Accepted: 07/29/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Small bowel obstruction (SBO) is a common cause of emergency presentations for abdominal pain and can be complicated by mesenteric ischemia. Computed tomography is currently central to diagnosis and management planning. Currently accepted signs identify secondary effects of the root physiological insult, which is vascular obstruction. We hypothesized that with advancements in CT technology and reconstruction algorithms, we can now more closely interrogate the mesenteric vasculature for obstruction and more accurately predict the need for surgical intervention. METHODS We retrospectively audited the charts of all patients presenting with a clinical diagnosis of SBO at a single institution in a 12-month period. Two blinded consultant radiologists were then asked to analyze 3D MIP reconstruction CT scans for vascular obstruction in addition to any currently accepted signs of ischemia. Comparison between vascular cutoff and accepted current signs in the need for surgical intervention and the presence of any signs of ischemia in theater were recorded. RESULTS Vascular cutoff had a comparable, with a trend towards superiority, sensitivity and specificity and inter-observer agreement to currently accepted signs of ischemia. The absence of a cut off sign has an excellent negative predictive value for ischemia with only 2 (3.7%) patients demonstrating ischemia at surgery where the vascular cutoff sign was not seen to be present. CONCLUSION Interrogating vascular obstruction using 3D MIP reconstructions in small bowel obstruction may be a more sensitive and specific sign for prediction of surgical intervention, possibly occurring earlier in the obstruction pathway.
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Affiliation(s)
- Baillie Ferris
- Department of Surgery, QEII Hospital, QLD, Cnr of Kessels and Troughton Rd, Coopers Plains, QLD, 4108, Australia.
- Greenslopes Hospital, Newdegate St, Greenslopes, QLD, 4120, Australia.
| | - Matthew Bastian-Jordan
- Queensland X-Ray, QEII Hospital, QLD, Cnr of Kessels and Troughton Rd, Coopers Plains, QLD, 4108, Australia
| | - John Fenwick
- Queensland X-Ray, QEII Hospital, QLD, Cnr of Kessels and Troughton Rd, Coopers Plains, QLD, 4108, Australia
| | - Jacqui Hislop-Jambrich
- Canon Medical Systems Australia and New Zealand, Level 4, 1 Acacia Place, Notting Hill, VIC, 3168, Australia
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48
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Ammirati CA, Allaix ME, Zago M. Small Bowel Obstruction. EMERGENCY LAPAROSCOPIC SURGERY IN THE ELDERLY AND FRAIL PATIENT 2021:181-186. [DOI: 10.1007/978-3-030-79990-8_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Tang W, Jin B, Kuang LQ, Zhang J, Li CX, Wang Y. Risk factors of geriatrics index of comorbidity and MDCT findings for predicting mortality in patients with acute mesenteric ischemia due to superior mesenteric artery thromboembolism. Br J Radiol 2020; 93:20190605. [PMID: 32886528 DOI: 10.1259/bjr.20190605] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To identify risk factors of geriatrics index of comorbidity (GIC) and multidetector CT (MDCT) findings for predicting mortality in patients with acute mesenteric ischemia (AMI) due to superior mesenteric artery (SMA) thromboembolism. METHODS 33 patients with AMI due to SMA thromboembolism underwent abdominal MDCT and angiography. Patients' comorbidities and MDCT findings of ischemic bowel/mesenteric injuries, regions of SMA involved by thromboembolism, and degrees of SMA stenosis were retrospectively reviewed. The comorbidities were classified into 1-4 levels according to GIC. The association of MDCT signs and GIC classification with mortality were analyzed. Diagnostic performances of risk factors associated with mortality were evaluated by receiver operating characteristic (ROC) curve analyses. RESULTS Eighteen patients (54.5%) died during hospitalization or follow-up, including one patient with class 1, two patients with class 2, eight patients with class 3, and seven patients with class 4 according to GIC. Three risk factors significantly associated with mortality were identified, including pneumatosis and/or portomesenteric venous gas (PPMVG) (p = 0.017), four regions of SMA involved by thromboembolism (region I + II + III + IV) (p = 0.036), and class 3 + 4 of comorbidities (p = 0.001). The sensitivity and specificity of PPMVG, region I + II + III + IV, class 3 + 4 of comorbidities, and the three risk factors combined for diagnosing mortality were 33.3 and 100%, 27.8 and 100%, 83.3 and 73.3%, and 88.9 and 73.3%, respectively. The areas under the ROC curve (AUC) of the three risk factors combined (0.88) and class 3 + 4 of comorbidities (0.78) were larger than that of PPMVG (0.67) and region I + II + III + IV (0.64). The mortality rate rose from 15.4% in patients without risk factor to 66.7%, 100%, and 100% in patients with one, two, and three factors, respectively. CONCLUSION Three risk factors for mortality were identified in patients with AMI due to SMA thromboembolism, including PPMVG and four regions of SMA involved by thromboembolism on MDCT images, and class 3 + 4 of comorbidities. Close monitoring of these risk factors could possibly lower the mortality. ADVANCES IN KNOWLEDGE Risk factors based on GIC and MDCT findings may be used to predict mortality in patients with AMI. Close monitoring of these risk factors could possibly lower the mortality.
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Affiliation(s)
- Wei Tang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China.,Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Bo Jin
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Lian-Qin Kuang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Jing Zhang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Chun-Xue Li
- Department of Gastrointestinal Surgery, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Yi Wang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
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Kim J, Lee Y, Yoon JH, Lee HJ, Lim YJ, Yi J, Jung WB. Non-strangulated adhesive small bowel obstruction: CT findings predicting outcome of conservative treatment. Eur Radiol 2020; 31:1597-1607. [PMID: 33128599 DOI: 10.1007/s00330-020-07406-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/24/2020] [Accepted: 10/09/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To clarify CT findings that predict outcome of conservative treatment in patients with non-strangulated adhesive small bowel obstruction (SBO). METHODS Unenhanced and contrast-enhanced abdominopelvic CT studies in 189 patients with adhesive SBO who had initial conservative treatment were reviewed. The CT findings included transition zone, beak signs, maximum bowel diameter, bowel diameter ratio, decreased bowel wall enhancement, increased unenhanced bowel wall attenuation, anterior parietal adhesion, bowel wall thickening, closed-loop obstruction, small bowel feces sign, whirl sign, mesenteric haziness, mesenteric, peritoneal fluid, and submucosal edema. These findings were statistically compared according to the success or failure of treatment. RESULTS Conservative treatment succeeded in 144 patients (76.2%) and failed in 45 patients (23.8%). At multivariate analysis, the lack of small bowel feces sign, focal, diffuse mesenteric haziness, and moderate amount of mesenteric fluid were independent findings predicting failure of conservative treatment, with odds ratios of 5.23, 5.5, 13.55, and 4.89, respectively. The presence of all significant findings showed a high specificity of 97.2% with positive likelihood ratio of 8.8. If CT scans showed none of the three significant findings, the negative predictive value was 97.6% and negative likelihood ratio was 0.08. CONCLUSIONS The lack of small bowel feces sign, focal, diffuse mesenteric haziness, and moderate amount of mesenteric fluid are independent CT findings predicting the failure of conservative treatment in patients with non-strangulated adhesive SBO. The combination of all CT findings suggests the need for surgery; absence of two or all CT findings should suggest an attempt for conservative treatment. KEY POINTS • To minimize delayed operation, it is important to identify non-strangulated adhesive small bowel obstruction patients in whom initial conservative treatment is likely to fail. • The lack of small bowel feces sign, the presence of mesenteric haziness, and a moderate amount of mesenteric fluid are independent factors predicting the failure of conservative treatment in patients with non-strangulated adhesive small bowel obstruction. • The combination of all three CT findings suggests the need for surgery; absence of two or all three CT findings should suggest an attempt for conservative treatment.
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Affiliation(s)
- Jieun Kim
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea.,Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yedaun Lee
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea.
| | - Jung-Hee Yoon
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Ho-Joon Lee
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Yun-Jung Lim
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Jisook Yi
- Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, Busan, 48108, South Korea
| | - Won Beom Jung
- Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
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