CLINICAL AND SURGICAL DILEMMAS IN OCTOGENARIAN PATIENTS WITH SMALL BOWEL OBSTRUCTION.

BACKGROUND: Small bowel obstruction (SBO) is a major problem in emergencies. Comorbidities increase morbimortality, which is reflected in higher costs. There is a lack of Latin American evidence comparing the differences in postoperative results and costs associated with SBO management. AIMS: To compare the risk of surgical morbimortality and costs of SBO surgery treatment in patients older and younger than 80 years. METHODS: Retrospective analysis of patients diagnosed with SBO at the University of Chile Clinic Hospital from January 2014 to December 2017. Patients with any medical treatment were excluded. Parametric statistics were used (a 5% error was considered statistically significant, with a 95% confidence interval). RESULTS: A total of 218 patients were included, of which 18.8% aged 80 years and older. There were no differences in comorbidities between octogenarians and non-octogenarians. The most frequent etiologies were adhesions, hernias, and tumors. In octogenarian patients, there were significantly more complications (46.3 vs. 24.3%, p=0.007, p<0.050). There were no statistically significant differences in terms of surgical complications: 9.6% in <80 years and 14.6% in octogenarians (p=0.390, p>0.050). In medical complications, a statistically significant difference was evidenced with 22.5% in <80 years vs 39.0% in octogenarians (p=0.040, p<0.050). There were 20 reoperated patients: 30% octogenarians and 70% non-octogenarians without statistically significant differences (p=0.220, p>0.050). Regarding hospital stay, the average was significantly higher in octogenarians (17.4 vs. 11.0 days; p=0.005, p<0.050), and so were the costs, being USD 9,555 vs. USD 4,214 (p=0.013, p<0.050). CONCLUSIONS: Patients aged 80 years and older with surgical SBO treatment have a higher risk of medical complications, length of hospital stay, and associated costs compared to those younger.

Clinical features of intussusception in children secondary to small bowel tumours: a retrospective study of 31 cases.

BACKGROUND: Summarizing the clinical features of children with intussusception secondary to small bowel tumours and enhancing awareness of the disease. METHODS: Retrospective summary of children with intussusception admitted to our emergency department from January 2016 to January 2022, who underwent surgery and were diagnosed with small bowel tumours. Summarize the types of tumours, clinical presentation, treatment, and prognosis. RESULTS: Thirty-one patients were included in our study, 24 males and 7 females, with an age of onset ranging from 1 m to 11y 5 m. Post-operative pathology revealed 4 types of small intestinal tumour, 17 lymphomas, 10 adenomas, 4 inflammatory myofibroblastomas and 1 lipoma. The majority of tumours in the small bowel occur in the ileum (83.9%, 26/31). Abdominal pain, vomiting and bloody stools were the most common clinical signs. Operative findings indicated that the small bowel (54.8%, 17/31) and ileocolic gut were the main sites of intussusception. Two types of procedure were applied: segmental bowel resection (28 cases) and wedge resection of mass in bowel wall (3 cases). All patients recovered well postoperatively, with no surgical complications observed. However, the primary diseases leading to intussusception showed slight differences in long-term prognosis due to variations in tumor types. CONCLUSIONS: Lymphoma is the most common cause of intussusception in pediatric patients with small bowel tumours, followed by adenoma. Small bowel tumours in children tend to occur in the ileum. Therefore, the treatment of SBT patients not only requires surgeons to address symptoms through surgery and obtain tissue samples but also relies heavily on the expertise of pathologists for accurate diagnosis. This has a significant impact on the overall prognosis of these patients.

Capsule endoscopy and panendoscopy: A journey to the future of gastrointestinal endoscopy.

In 2000, the small bowel capsule revolutionized the management of patients with small bowel disorders. Currently, the technological development achieved by the new models of double-headed endoscopic capsules, as miniaturized devices to evaluate the small bowel and colon [pan-intestinal capsule endoscopy (PCE)], makes this non-invasive procedure a disruptive concept for the management of patients with digestive disorders. This technology is expected to identify which patients will require conventional invasive endoscopic procedures (colonoscopy or balloon-assisted enteroscopy), based on the lesions detected by the capsule, i.e., those with an indication for biopsies or endoscopic treatment. The use of PCE in patients with inflammatory bowel diseases, namely Crohn's disease, as well as in patients with iron deficiency anaemia and/or overt gastrointestinal (GI) bleeding, after a non-diagnostic upper endoscopy (esophagogastroduodenoscopy), enables an effective, safe and comfortable way to identify patients with relevant lesions, who should undergo subsequent invasive endoscopic procedures. The recent development of magnetically controlled capsule endoscopy to evaluate the upper GI tract, is a further step towards the possibility of an entirely non-invasive assessment of all the segments of the digestive tract, from mouth-to-anus, meeting the expectations of the early developers of capsule endoscopy.

Small bowel anastomosis in emergency surgery.

BACKGROUND: Emergency laparotomy is associated with a high morbidity and mortality rate. The decision on whether to perform an anastomosis or an enterostomy in emergency small bowel resection is guided by surgeon preference alone, and not evidence based. We examined the risks involved in small bowel resection and anastomosis in emergency surgery. METHODS: A retrospective study from 2016 to 2019 in a university hospital in Denmark, including all emergency laparotomies, where small-bowel resections, ileocecal resections, right hemicolectomies and extended right hemicolectomies where performed. Demographics, operative data, anastomosis or enterostomy, as well as postoperative complications were recorded. Primary outcome was the rate of bowel anastomosis. Secondary outcomes were the anastomotic leak rate, mortality and complication rates. RESULTS: During the 3.5-year period, 370 patients underwent emergency bowel resection. Of these 313 (84.6%) received an anastomosis and 57 (15.4%) an enterostomy. The 30-day mortality rate was 12.7% (10.2% in patients with anastomosis and 26.3% in patients with enterostomy). The overall anastomotic leak rate was 1.6%, for small-bowel to colon 3.0% and for small-bowel to small-bowel 0.6%. CONCLUSION: A primary anastomosis is performed in more than eight out of 10 patients in emergency small bowel resections and is associated with a very low rate of anastomotic leak.

Mesenteric sparing approach for advanced nodal extent in small intestinal neuroendocrine tumors. Is there a limit to the vascular resection in order to avoid creating a short small bowel syndrome? An anatomic research study.

PURPOSE: By selectively perfusing the first three jejunal arteries (JA), we aim to assess the individual perfusion length of small bowel (SB) and its impact on nodal resection in stage III-up small-intestinal neuroendocrine tumors (SI-NET). METHODS: Our anatomical research protocol implies a midline laparotomy and three measures of the SB length. We then perform a classical anterior approach of the superior mesenteric vessels. We carry on with the complete dissection and checking of the superior mesenteric artery (SMA) in order to identify the first three JA. Then we selectively perfuse each artery with colored latex solutions and measure the length of small bowel perfused respectively. RESULTS: We conducted our protocol on six cadaveric subjects. Mean(SD) SB length was 413(5.7), 535(13.2), 485(15), 353(25.1), 730(17.3) and 525(16° cm respectively from subject one to six. Most JA originated from the left side of the SMA. The first JA originated from its posterior wall in two subjects. Mean(SD) distance of origin of the first three JA was 4.6(1.3)cm, 6(1.1)cm and 7.1(0.9)cm respectively. Mean(SD) diameter of SMA was 10.8(3.3)mm. Mean diameter of the three first JA was 4(1.4)mm, 4(1.5)mm and 5(1.2)mm respectively. Mean(SD) SB length perfused by first and second JA was 224(14.9)cm, 175(8.6)cm, 238.3(7.6)cm, 84.3(5.1)cm, 233.3(5.8)cm and 218.3(10.4)cm respectively from subject one to six. CONCLUSION: We observed a trend suggesting that the first and second JA may sustain a SB length beyond the viable 1.5 m limit, implying the feasibility of stage III-up SI-NET resection with just two JA.

Can small bowel obstruction during pregnancy be treated with conservative management? A review.

BACKGROUND: Small bowel obstruction can occur during pregnancy, which, if missed, can lead to dire consequences for both the mother and foetus. Management of this condition usually requires surgical intervention. However, only a small number of patients are treated conservatively. OBJECTIVE: The objective was to review the literature to determine the feasibility of conservative management for small bowel obstruction. METHODS: A systematic search of the PubMed and Embase databases was performed using the keywords [small bowel obstruction AND pregnancy]. All original articles were then reviewed and included in this review if deemed suitable. CONCLUSION: Conservative management of small bowel obstruction in pregnant women is feasible if the patient is clinically stable and after ruling out bowel ischaemia and closed-loop obstruction.

Risk factors for surgery in stricturing small bowel Crohn's disease: A retrospective cohort study from the GETAID pédiatrique.

OBJECTIVES: Previous studies have shown rates of surgical resection of up to 41% in stricturing pediatric Crohn's disease (CD). In this retrospective multicenter study, our aims were to identify clinical risk factors and magnetic resonance enterography (MRE) features of small bowel strictures associated with surgery. METHODS: Pediatric patients with symptomatic stricturing small bowel CD (defined as obstructive symptoms or proximal dilatation on MRE) confirmed by MRE between 2010 and 2020 were recruited from 12 French tertiary hospitals. Patient characteristics were compared by surgical outcome multivariable Cox regression. RESULTS: Fifty-six patients (61% boys) aged 12.2 ± 2.7 years at diagnosis of CD were included. Median duration of CD before diagnosis of stricture was 11.7 months (interquartile range [IQR]: 25-75: 1.2-29.9). Nineteen (34%) patients had stricturing phenotype (B2) at baseline. Treatments received  before stricture diagnosis included MODULEN-IBD (n = 31), corticosteroids (n = 35), antibiotics (n = 10), anti-TNF (n = 27), immunosuppressants (n = 28). Thirty-six patients (64%) required surgery, within 4.8 months (IQR: 25-75: 1.8-17.3) after stricture diagnosis. Parameters associated with surgical resection were antibiotic exposure before stricture diagnosis (adjusted odds ratio [aOR]: 15.62 [3.35-72.73], p = 0.0005), Crohn's disease obstructive symptoms score (CDOS) > 4 (aOR: 3.04 [1.15-8.03], p = 0.02) and dilation proximal to stricture >28 mm (aOR: 3.62 [1.17-11.20], p = 0.03). CONCLUSION: In this study, antibiotic treatment before stricture diagnosis, intensity of obstructive symptoms, and diameter of dilation proximal to small bowel stricture on MRE were associated with risk for surgical resection.

Frailty in inflammatory bowel disease: analysis of the National Inpatient Sample 2015-2019.

AIM: Preoperative frailty has been associated with adverse postoperative outcomes in various populations, but of its use in patients with inflammatory bowel disease (IBD) remains sparse. The present study aimed to characterize the impact of frailty, as measured by the modified frailty index (mFI), on postoperative clinical and resource utilization outcomes in patients with IBD. METHODS: This retrospective population-based cohort study assessed patients from the National Inpatient Sample database from 1 September 2015 to 31 December 2019. Corresponding International Classification of Diseases 10th Revision Clinical Modification codes were used to identify adult patients (>18 years of age) with IBD, undergoing either small bowel resection, colectomy or proctectomy. Patient demographics and institutional data were collected for each patient to calculate the 11-point mFI. Patients were categorized as either frail or robust using a cut-off of 0.27. Primary outcomes were postoperative in-hospital morbidity and mortality, whilst secondary outcomes included system-specific morbidity, length of stay, in-hospital healthcare costs and discharge disposition. Logistic and linear regression models were used for primary and secondary outcomes. RESULTS: Overall, 7144 patients with IBD undergoing small bowel resection, colectomy or proctectomy were identified, 337 of whom were classified as frail (i.e., mFI < 0.27). Frail patients were more likely to be women, older, have lower income and a greater number of comorbidities. After adjusting for relevant covariates, frail patients were at greater odds of in-hospital mortality (adjusted odds ratio [aOR] 5.42, 95% CI 2.31-12.77, P < 0.001), overall morbidity (aOR 1.72, 95% CI 1.30-2.28, P < 0.001), increased length of stay (adjusted mean difference 1.3 days, 95% CI 0.09-2.50, P = 0.035) and less likely to be discharged to home (aOR 0.59, 95% CI 0.45-0.77, P < 0.001) compared to their robust counterparts. CONCLUSIONS: Frail IBD patients are at greater risk of postoperative mortality and morbidity, and reduced likelihood of discharge to home, following surgery. This has implications for clinicians designing care pathways for IBD patients following surgery.

Assessing the influence of parameters on tissue welding in small bowel end-to-end anastomosis in vitro and in vivo.

BACKGROUND: The use of high-frequency electric welding technology for intestinal end-to-end anastomosis holds significant promise. Past studies have focused on in vitro, and the safety and efficacy of this technology is uncertain, severely limiting the clinical application of this technology. This study investigates the impact of compression pressure, energy dosage, and duration on anastomotic quality using a homemade anastomosis device in both in vitro and in vivo settings. METHODS: Two hundred eighty intestines and 5 experimental pigs were used for in vitro and in vivo experiments, respectively. The in vitro experiments were conducted to study the effects of initial pressure (50-400 kpa), voltage (40-60 V), and time (10-20 s) on burst pressure, breaking strength, thermal damage, and histopathological microstructure of the anastomosis. Optimal parameters were then inlaid into a homemade anastomosis and used for in vivo experiments to study the postoperative porcine survival rate and the pathological structure of the tissues at the anastomosis and the characteristics of the collagen fibers. RESULTS: The anastomotic strength was highest when the compression pressure was 250 kPa, the voltage was 60 V, and the time was 15 s. The degree of thermal damage to the surrounding tissues was the lowest. The experimental pigs had no adverse reactions after the operation, and the survival rate was 100%. 30 days after the operation, the surgical site healed well, and the tissues at the anastomosis changed from immediate adhesions to permanent connections. CONCLUSION: High-frequency electric welding technology has a certain degree of safety and effectiveness. It has the potential to replace the stapler anastomosis in future and become the next generation of new anastomosis device.

[A Case of Desmoid-Type Fibromatosis of the Mesentery of Small Intestine].

Desmoid-type fibromatosis is a relatively rare disease, often associated with familial adenomatous polyposis and a history of abdominal surgery. A 43-year-old male patient presented with abdominal pain and contrast-enhanced CT showed a mass in the lower abdomen. The mass was a 4×4×3 cm white, dense tumor with a wreath-like arrangement of eosinophilic spindle-shaped cells. Immunostaining showed KIT(-), CD34(-), desmin(-), ß-catenin(+), SMA(few+), and the diagnosis was desmoid-type fibrosis. Six months after surgery, there was no apparent recurrence.

Contemporary Assessment of Adhesiolysis and Resection for Adhesive Small Bowel Obstruction in the State of New York.

BACKGROUND: Adhesive small bowel obstruction (aSBO) is a common surgical problem, with some advocating for a more aggressive operative approach to avoid recurrence. Contemporary outcomes in a real-world setting were examined. STUDY DESIGN: A retrospective cohort study was performed using the New York Statewide Planning and Research Cooperative database to identify adults admitted with aSBO, 2016-2020. Patients were stratified by the presence of inflammatory bowel disease (IBD) and cancer history. Diagnoses usually requiring resection were excluded. Patients were categorized into four groups: non-operative, adhesiolysis, resection, and 'other' procedures. In-hospital mortality, major complications, and odds of undergoing resection were compared. RESULTS: 58,976 patients were included. 50,000 (84.8%) underwent non-operative management. Adhesiolysis was the most common procedure performed (n = 4,990, 8.46%), followed by resection (n = 3,078, 5.22%). In-hospital mortality in the lysis and resection groups was 2.2% and 5.9% respectively. Non-IBD patients undergoing operation on the day of admission required intestinal resection 29.9% of the time. Adjusted odds of resection were highest for those with a prior aSBO episode (OR 1.29 95%CI 1.11-1.49), delay to operation ≥3 days (OR1.78 95%CI 1.58-1.99), and non-New York City (NYC) residents being treated at NYC hospitals (OR1.57 95%CI 1.19-2.07). CONCLUSION: Adhesiolysis is currently the most common surgery for aSBO, however nearly one-third of patients will undergo a more extensive procedure, with an increased risk of mortality. Innovative therapies are needed to reduce the risk of resection.

Management of a Complex Fistula Involving Abdominal Wall, Small Bowel, Colon, and Bladder.

Successful surgical management of a chronic complex abdominal fistula requires thoughtful pre-operative evaluation and planning and often benefits from a multi-disciplinary approach. Initially, attention is focused on controlling sepsis and ensuring adequate hydration and electrolyte replacement. Next, efforts to optimize nutrition and engage the patient in prehabilitation are prioritized. Simultaneously, imaging is used to gain detailed assessment of anatomy. We present a challenging case involving a Jackson-Pratt (JP) drain from prior surgery causing a complex intra-abdominal fistula. The JP drain traversed multiple small bowel loops and the sigmoid colon before terminating in the bladder. Management required multi-disciplinary coordination involving colorectal surgery and urology. The patient's definitive surgery included anterior resection, colostomy takedown, right colectomy, three small bowel resections, and bladder repair. The use of JP drains after abdominal surgery is not without risk. Clinicians should have standardized indications for placement of JP drains and consistent protocols regarding timing of removal.

Modified Graham Patch Repair of Small Bowel Anastomotic Leak.

The modified Graham patch repair is a well-established technique for management of perforating foregut injuries, often learned by surgeons during general surgery training. There is, however, little to no data regarding the utilization of this technique for perforation of the distal midgut or in the re-operative field. We present two cases of midgut anastomotic complications successfully managed with modified graham patch repair at our institution. The first case is a 79-year-old female who underwent an emergent right hemicolectomy at an outside institution for management of an iatrogenic perforation during endoscopic polypectomy. Over the course of two years she underwent numerous abdominal operations, due to various complications, ultimately resulting in multiple resections and end ileostomy creation. She then had her ileostomy reversed by laparoscopic single incision (SILS) technique at our institution. This was also complicated by anastomotic leak. Intraoperatively, adequate mobilization of the anastomosis for resection was deemed not safe due to dense fibrosis and adhesions in the re-operative field; therefore, she underwent a SILS modified Graham patch repair of an ileocolic anastomotic defect with diverting loop ileostomy. Post-operatively, she had no radiographic evidence of leak from the repaired anastomosis, which facilitated successful loop ileostomy reversal five months later. Our second case is a 64-year-old male referred to our institution for management of his stage IV colon cancer. He underwent an open right hemicolectomy and hepatic metastectomy, which was complicated by anastomotic leak. The small defect was repaired via a SILS modified Graham patch technique. Five months postoperatively, he had neither radiographic nor endoscopic evidence of a leak; therefore, he successfully underwent ileostomy reversal without complication. We encourage further investigation and reporting of the role of the modified graham patch repair in management of midgut anastomotic complications, particularly when resection and re-anastomosis is unsafe due to a hostile re-operative field.

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

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

Indications for Readmission for Small Bowel Obstruction: A Comparison of Medical vs Surgical Service Admission.

Small bowel obstruction (SBO) impacts the health care system and patient quality of life. Previously, we evaluated differences between medical and surgical admissions in the management of SBO. This study investigates indications for readmission based on original admission to medical (MS) or surgical services (SS). A retrospective chart review was performed for 799 patients aged 18 to 89 admitted between 2012 and 2019 with a diagnosis of SBO. Patient characteristics examined included length of stay (LOS), prior abdominal operations, prior SBO, use of small bowel follow through imaging, operative intervention, mortality, and 30-day readmission. There was no difference in readmission rates in patients originally admitted to MS or SS (13.2% vs 12.7%, P = .86). Patients admitted to SS were more likely to be readmitted for recurrent SBO (39% vs 8.6%, P = .006). Patients admitted to MS were more likely to be readmitted for other reasons (73.9% v. 40.2%, P = .004). In the MS cohort, 30.4% (7 patients) had surgery during their initial admission for SBO, and none of those patients were readmitted for recurrent SBO (rSBO). In the SS cohort, 23% had surgery during their initial admission and 31.6% were readmitted for rSBO (P = .002). Patients admitted to SS were more likely to be readmitted for rSBO and to require surgery. Patients admitted to MS were more likely to be readmitted for other reasons. None of the MS patients who had surgery were readmitted for SBO. 31.6% of SS patients who had surgery were readmitted for SBO.

How to do a laparoscopic-assisted endoscopic 'clean sweep' for small bowel polyp clearance in Peutz Jeghers syndrome.

We demonstrate the technical details of laparoscopic-assisted endoscopic 'clean sweep' for small bowel polyp clearance in Peutz Jeghers Syndrome. A 'clean sweep' reduces the risk for future recurrences but was previously performed with an open technique. A minimally invasive approach is safe, reduces bowel trauma and has good postoperative outcomes.