Nutritional Status as a Prognostic Factor for Survival in Palliative Care: A Retrospective Observational Analysis of Home Parenteral Nutrition in Cancer Patients with Inoperable Malignant Bowel Obstruction.

Palliative care patients with malignant bowel obstruction are particularly at risk of developing malnutrition, which in turn directly shortens survival time and worsens quality of life (QoL). According to the available data, the survival time in this patient group is often less than three months. To avoid further complications related to malnutrition and poor outcomes in oncological therapy, nutritional therapy such as home parenteral nutrition (HPN) is offered. The aim of this study was to investigate whether nutritional status is a prognostic factor for survival in palliative care patients with malignant inoperable bowel obstruction qualified for home parenteral nutrition and which nutritional assessment tool has the most accurate prognostic value. This retrospective observational analysis included 200 patients with malignant bowel obstruction referred for home parenteral nutrition between January 2018 and August 2023. The analysis included laboratory test results, body mass index (BMI), Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Geriatric Nutritional Risk Index (GNRI), Prognostic Nutritional Index (PNI) and malnutrition as defined by the Global Leadership Initiative on Malnutrition (GLIM). The average survival time of the patients was 75 days. Patients with higher NRI and PNI scores were more likely to survive (NRI: p < 0.001; PNI: p < 0.001). The GLIM criteria, SGA scores and BMI values did not prove to be good prognostic factors for survival (GLIM p = 0.922, SGA p = 0.083, BMI p = 0.092). The results suggest that the use of NRI and PNI may be helpful in prognosing survival in these patients and that prevention of the development of malnutrition through earlier nutritional assessment and intervention should be considered in this patient group.

Evaluation of clinical profiles, surgical experience and outcomes of ileosigmoid knotting in low-resource setup: A retrospective cohort study at Jimma University Medical Center.

BACKGROUND: Bowel obstruction is a mechanical or functional blockade of intestinal contents from evacuation to the adjacent distal bowel or external environment. It poses significant morbidity and mortality in both high-income and low-to-middle-income countries. Ileosigmoid knotting is a special form of obstruction where the small bowel often ileum wraps around the sigmoid colon or vice versa. It is the severest form of bowel obstruction, involving both the small and large bowels in a compound manner. It is common where sigmoid volvulus is common and geographic areas with a bulky diet. METHODS: An institution-based retrospective cohort study was employed among purposively selected 40 surgical patients with ileosigmoid knotting records from July 2020 to July 2023 at Jimma University Medical Center. To estimate and compare the survival probabilities, the Kaplan-Meir method and log-rank test were used. A Cox-regression analysis was fitted to identify independent predictors of time to death. RESULTS: Among a cohort of 40 patients followed for 347 person-days at Jimma University Medical Center, 11 (27.5%) had died. The overall incidence rate of death was 3.2 (95% CI 1.8, 5.7) per 100 person-days. In multivariable Cox-regression analysis, age (AHR = 1.15; 95% CI: 1.04-1.28), shock at presentation (AHR = 30.50: 95% CI 1.25-742.54), comorbidities (AHR = 5.81; 95% CI 1.19-28.23), pulse rate intraoperatively (AHR = 1.19; 95% CI: 1.01-1.40), postoperative pulse rate (AHR = 1.07; 95% CI: 1.01-1.14) were independently associated with time to death. CONCLUSION: The incidence of death among surgical patients with ileosigmoid knotting was high and also had a shorter median survival time. Age, shock at presentation, comorbidities, pulse rate intraoperatively, and postoperative pulse rate were found to be statistically significant predictors of time to death and outcome among surgical patients with Ileosigmoid knotting.

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.

Relief of Obstruction in Left-Sided Obstructive Colon Cancer: Nationwide Analysis of Applied Treatment in the Palliative Setting.

BACKGROUND: For relief of bowel obstruction in left-sided obstructive colon cancer (LSOCC), a self-expandable metal stent (SEMS) or decompressing stoma (DS) can be placed. In a curative setting, these two strategies have been extensively studied as a bridge to elective resection. Guidelines recommend SEMS as the preferred option in the palliative setting, but adherence in daily practice is unknown. Therefore, this study aimed to gain more insight into patients with LSOCC who received palliative treatment with SEMS or DS at a national level. METHODS: A retrospective population-based cohort study was conducted in the Netherlands. Data from the Netherlands Cancer Registry (NCR) on all patients with LSOCC treated with DS or SEMS not followed by resection of the primary tumour between January 1, 2015, and December 31, 2019, were analysed. Type of treatment (DS or SEMS) for different clinical scenarios, was the main outcome of this study, and was also evaluated over the years (2015-2019). RESULTS: Palliative treatment with SEMS or DS for LSOCC was performed in 1077 patients, of whom 79.2% had metastatic disease (M1). Patients without metastatic disease (M0) were older (≥ 80 years M0 67.4%, M1 25.3%, P < 0.001), had a worse clinical condition (ASA III 51.4% versus 36.37%, ASA IV-V 13.3% versus 4.0% P < 0.001) and presented with higher tumour stage (cT4 55.4% versus 33.5%, % P < 0.001). DS was performed in 91.5% of the patients and SEMS in 8.5%. The proportion of DS did not significantly differ between patients with M1 and M0 (91.8% vs. 90.2% respectively, P = 0.525). No increase in SEMS application was observed over the years, with a stable overall proportion of DS of 91-92% per year. In the multivariable analyses, ninety-day mortality and overall survival were not significantly different between SEMS and DS. CONCLUSIONS: This study revealed that DS was the primary treatment modality for palliative management of LSOCC in the Netherlands between 2015 and 2019, while the guidelines recommended SEMS as preferred treatment. For patients with LSOCC eligible for stenting in the palliative setting, SEMS placement should become more available and accessible as the preferred treatment option, to avoid a stoma in the terminal phase of life.

Improving outcomes in emergency general surgery: Construct of a collaborative quality initiative.

BACKGROUND: Emergency general surgery conditions are common, costly, and highly morbid. The proportion of excess morbidity due to variation in health systems and processes of care is poorly understood. We constructed a collaborative quality initiative for emergency general surgery to investigate the emergency general surgery care provided and guide process improvements. METHODS: We collected data at 10 hospitals from July 2019 to December 2022. Five cohorts were defined: acute appendicitis, acute gallbladder disease, small bowel obstruction, emergency laparotomy, and overall aggregate. Processes and inpatient outcomes investigated included operative versus nonoperative management, mortality, morbidity (mortality and/or complication), readmissions, and length of stay. Multivariable risk adjustment accounted for variations in demographic, comorbid, anatomic, and disease traits. RESULTS: Of the 19,956 emergency general surgery patients, 56.8% were female and 82.8% were White, and the mean (SD) age was 53.3 (20.8) years. After accounting for patient and disease factors, the adjusted aggregate mortality rate was 3.5% (95% confidence interval [CI], 3.2-3.7), morbidity rate was 27.6% (95% CI, 27.0-28.3), and the readmission rate was 15.1% (95% CI, 14.6-15.6). Operative management varied between hospitals from 70.9% to 96.9% for acute appendicitis and 19.8% to 79.4% for small bowel obstruction. Significant differences in outcomes between hospitals were observed with high- and low-outlier performers identified after risk adjustment in the overall cohort for mortality, morbidity, and readmissions. The use of a Gastrografin challenge in patients with a small bowel obstruction ranged from 10.7% to 61.4% of patients. In patients who underwent initial nonoperative management of acute cholecystitis, 51.5% had a cholecystostomy tube placed. The cholecystostomy tube placement rate ranged from 23.5% to 62.1% across hospitals. CONCLUSION: A multihospital emergency general surgery collaborative reveals high morbidity with substantial variability in processes and outcomes among hospitals. A targeted collaborative quality improvement effort can identify outliers in emergency general surgery care and may provide a mechanism to optimize outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Evaluating whether KRAS/BRAF mutation status, anaemia and obstruction are associated with recurrence and mortality in non-metastatic colorectal cancer.

BACKGROUND: KRAS and BRAF testing is currently recommended in metastatic colorectal cancer. There is evidence that KRAS and BRAF mutation status may act as a prognostic biomarker in patients with non-metastatic colorectal cancer. Data is limited on whether KRAS and BRAF mutation status impacts recurrence and mortality in patients with non-metastatic colorectal cancer. METHODS: A retrospective cohort study was conducted in a tertiary hospital examining outcomes in patients who had KRAS and BRAF testing for colorectal cancer in 2017. Primary outcomes were all-cause mortality and recurrence. Multivariable analysis for both outcomes, used cause specific Cox proportional hazards models with KRAS/BRAF status as exposure. For time to recurrence, a sensitivity analysis was performed with a weighted Fine-Grey model with death as a competing risk. RESULTS: KRAS mutation status was not associated with all-cause mortality (average Hazard Ratio (aHR) = 0.78, 95% CI 0.28-2.21) or recurrence (aHR = 0.96, 95% CI 0.32-2.86). BRAF mutation status was not associated with time to all-cause mortality (aHR = 3.06, 95% CI 0.79-11.8) or recurrence (aHR = 0.94, 95% CI 0.13-6.57). Increased risk of recurrence was significantly associated with large bowel obstruction (aHR = 2.73, 95% CI 1.16-6.45) and anaemia (aHR = 3.39, 95% CI 1.06-10.8) at time of surgery. CONCLUSION: This study did not demonstrate an association between KRAS and BRAF mutations and all-cause mortality or recurrence. A significantly increased risk of cancer recurrence was found in patients with large bowel obstruction and in patients with anaemia at time of surgery. Anaemia should be promptly investigated and corrected prior to colorectal cancer surgery.

Self-Expanding Metal Stents Do Not Adversely Affect Long-term Outcomes in Acute Malignant Large-Bowel Obstruction: A Retrospective Analysis.

BACKGROUND: Self-expanding metal stents as a bridge to surgery in acute malignant large-bowel obstruction has gained popularity. However, long-term oncologic outcomes have not been well established. OBJECTIVE: To investigate long-term oncologic outcomes of patients undergoing curative resection after the placement of a colonic stent compared with emergency surgery for acute malignant large-bowel obstruction. DESIGN: This is a retrospective study. SETTING: All patients presenting at 3 tertiary care centers between April 2002 and December 2012 with a diagnosis of complete malignant large-bowel obstruction were reviewed. Patients with disease distal to the hepatic flexure were selected for analysis. PATIENTS: One hundred twenty-two patients who underwent either emergency surgery or placement of a colonic stent with curative intent were included. INTERVENTIONS: Patients receiving emergency surgery within 24 hours of presenting with obstructive symptoms, including those with failed stents, were included in the emergency surgery group. All patients with clinically successful stent deployment before surgery were included in the stent group. MAIN OUTCOME MEASURES: Overall survival and disease-free survival were calculated using the Kaplan-Meier method. RESULTS: Sixty-four patients underwent emergency surgery, and 58 patients underwent placement of a self-expanding metal stent. Groups were similar in terms of sex, tumor stage and grade, and Charlson and Charlson-Age Comorbidity Index scores. Patients in the surgery group were older than patients in the stent group. There were no differences in the number of lymph nodes harvested, positive nodes, rates of vascular and perineural invasion, or utilization of chemotherapy. Thirty-day mortality after resection was similar between groups (7.41% vs 4.41%; p > 0.05). Patients who underwent colonic stenting as a bridge to surgery had similar 10-year overall survival (40.5% vs 32.7%; p = 0.13) and 10-year disease-free survival (40.2% vs 33.8%; p = 0.26) compared with those who underwent emergency surgery. Similar results were seen on intention-to-treat analysis. LIMITATIONS: This was a small retrospective study. CONCLUSIONS: Stent insertion followed by oncologic resection is associated with similar overall survival and disease-free survival compared with emergency resection. Stent insertion as a bridge to surgery should be considered in patients presenting with malignant colorectal obstruction. See Video Abstract at http://links.lww.com/DCR/B714Los Stents Metálicos Autoexpandibles No Afectan Negativamente Los Resultados A Largo Plazo En La Obstrucción Maligna Aguda Del Colon: Un Análisis Retrospectivo. ANTECEDENTES: Los stents metálicos autoexpandibles como puente a una cirugía en la obstrucción maligna aguda del colon han ganado popularidad. Sin embargo, no se han establecido bien los resultados oncológicos a largo plazo. OBJETIVO: Investigar los resultados oncológicos a largo plazo de los pacientes sometidos a resección curativa después de la colocación de un stent colónico en comparación con la cirugía de urgencia para la obstrucción maligna aguda del colon. DISEO: Estudio retrospectivo. MBITO: Entre abril de 2002 y diciembre de 2012, se revisaron todos los pacientes que acudieron a tres centros de tercer nivel con un diagnóstico de obstrucción maligna completa del colon. Se seleccionaron para el análisis los pacientes con enfermedad distal al ángulo hepático. PACIENTES: Se incluyeron 122 pacientes que fueron operados de urgencia o a una colocación de un stent colónico con intención curativa. PROCEDIMIENTOS: Los pacientes que se sometieron a cirugía de urgencia dentro de las 24 horas posteriores a la presentación de síntomas obstructivos; se incluyeron aquellos con stents fallidos en el grupo de cirugía de urgencia. Todos los pacientes con colocación clínicamente exitosa del stent antes de la cirugía se incluyeron en el grupo de stent. PRINCIPALES VARIABLES ANALIZADAS: La sobrevida global y la sobrevida libre de enfermedad se calcularon mediante el método de Kaplan-Meier. RESULTADOS: Sesenta y cuatro pacientes fueron llevados a cirugía urgente y en 58 pacientes se colocó de un stent metálico autoexpandible. Los grupos fueron similares en relación a sexo, estadio y grado del tumor, puntuación de comorbilidad de Charlson y Charlson-Age. Los pacientes del grupo de cirugía eran mayores que los del grupo de stents. No hubo diferencias en el número de ganglios linfáticos recolectados, ganglios positivos, tasas de invasión vascular y perineural o utilización de quimioterapia. La mortalidad a los 30 días después de la resección fue similar entre los grupos (7,41% frente a 4,41%; p> 0,05). Los pacientes que se sometieron a la colocación de un stent colónico como puente a la cirugía tuvieron una sobrevida general a diez años similar (40,5% vs 32,7%; p = 0,13) y una sobrevida libre de enfermedad a diez años (40,2% vs 33,8%, respectivamente; p = 0,26) en comparación a los operados de urgencia. Se observaron resultados similares en el análisis por intención de tratamiento. LIMITACIONES: Estudio retrospectivo reducido. CONCLUSIONES: La utilización de un stent y posteriormente la resección oncológica se asocia a una sobrevida general y una sobrevida libre de enfermedad similar en comparación con la resección de urgencia. La utilización de un stent como puente a la cirugía debe considerarse en pacientes que presentan obstrucción colorrectal maligna. Consulte Video Resumen en http://links.lww.com/DCR/B714. (Traducción-Dr. Lisbeth Alarcon-Bernes).

Delayed surgical resection of primary left-sided obstructing colon cancer is associated with improved short- and long-term outcomes.

BACKGROUND AND OBJECTIVES: It is unclear what time interval is optimal between presentation and surgical resection of left-sided obstructive colon cancer (LSOCC). This study aims to determine whether a time interval beyond 4 weeks is associated with a better outcome. MATERIALS AND METHODS: Consecutive patients who underwent surgical resection of LSOCC between January 2010 and December 2019 were collected from a prospective database. Patients were divided into three groups: (1) Emergency resection (ER group), (2) surgery in less than 4 weeks (early group), and (3) surgery beyond 4 weeks (late group). RESULTS: The ER group consisted of 74 (44.0%), the early group of 38 (22.6%), and the late group of 56 (33.3%) patients. Ninety-day mortality was lower in the Late group than in the ER group and the early group (1.8% vs. 12.2%, p = 0.029 vs. 15.3%, p = 0.011). In the late group 5-year recurrence-free survival was better than in the early group (82.1% vs. 63.2%, p = 0.039) and 5-year overall survival (OS) was better than in the ER group (75% vs. 51.4%, p = 0.021). Definitive surgical resection beyond 4 weeks was an independent prognostic factor for OS (Hazard ratio: 0.402, 95% CI: 0.204-0.793, p = 0.009). CONCLUSION: In this study surgical resection beyond 4 weeks after presentation seems to have a better short- and long-term outcome for LSOCC.

A single-centre ten-year retrospective cohort study of malignant small bowel obstruction.

INTRODUCTION: Management of malignant small bowel obstruction (mSBO) is challenging. The decision to perform an operation evaluates the perceived chance of success against a patient's fitness for operation. The aim of this study was to characterise the mSBO patient population in a tertiary UK centre and assess the patient's treatment pathway including use and effects of palliative surgery, total parenteral nutrition (TPN), Gastrografin and dexamethasone as well as preoperative stratification. METHODS: Patients were included if they had mSBO confirmed on computed tomography imaging due to a primary or metastatic neoplasm. Data were collected on pathway and management, and Cox proportional hazard methods were utilised to observe effects on survival. RESULTS: Ninety-four patients were included, with 104 inpatient episodes. Mean age was 67.4 (SD 13.7), with 57 (60.6%) females. Most (89.4%) had only one admission for mSBO. Eighty-four (89.4%) patients died over the ten-year period, 18 (17.3%) within 30 days of admission. Fifty patients (53.1%) underwent operative management: 70% bypass, 24% stoma formation and 6% open-close laparotomies. Log rank testing of survival probability analysis was significant (p = 0.00018), with 50% survival probability at 107.32 days for operative management and 47.87 days for non-operative. DISCUSSION AND CONCLUSION: Operative management forms part of the treatment pathway for a significant proportion of patients with mSBO, offering a survival benefit, though quality of survival is not known. Case selection is good, with few open-close laparotomies. Trials of non-operative interventions such as Gastrografin and dexamethasone are not utilised fully.

Socioeconomic risk factors for mortality and readmission after surgery for bowel obstruction: An analysis of the Nationwide Readmissions Database.

BACKGROUND: Small bowel obstructions (SBO) are one of the most common surgical emergencies, but they remain a major cause of high morbidity and mortality in patients with previous history of abdominal and pelvic surgery. Socioeconomic factors have not been extensively studied in surgical management of SBO. METHODS: We queried the 2016 NRD database for all surgically managed admissions ≥18 years of age with a primary diagnosis of SBO. The primary outcomes for this analysis were index admission mortality, 30-day mortality, and 30-day readmissions. Multivariate logistic regression models were utilized to examine the association between predictors and primary outcomes. RESULTS: Medicaid patients had a higher likelihood of index admission mortality. Medicare and Medicaid patients both had higher likelihoods of 30-day readmissions.results CONCLUSIONS: Careful consideration should be taken before deciding the optimal surgical approach in patients with SBO. Medicaid beneficiaries and those with existing comorbidities should receive careful post-operative follow-up to ensure optimal outcomes.

Long-term survival after self-expanding metallic stent or stoma decompression as bridge to surgery in acute malignant large bowel obstruction.

AIM: Self-expanding metallic stents (SEMS) as bridge to surgery have been questioned due to the fear of perforation and tumour spread. This study aimed to compare SEMS and stoma as bridge to surgery in acute malignant large bowel obstruction in the Swedish population. METHOD: Medical records of patients identified via the Swedish Colorectal Cancer Register 2007-2009 were collected and scrutinized. The inclusion criterion was decompression intended as bridge to surgery due to acute malignant large bowel obstruction. Patients who underwent decompression for other causes or had bowel perforation were excluded. Primary endpoints were 5-year overall survival and 3-year disease-free survival. Secondary endpoints were 30-day morbidity and mortality rates. RESULTS: A total of 196 patients fulfilled the inclusion criterion (SEMS, 71, and stoma, 125 patients). There was no significant difference in sex, age, ASA score, TNM stage and adjuvant chemotherapy between the SEMS and stoma groups. No patient was treated with biological agents. Five-year overall survival was comparable in SEMS, 56 per cent (40 patients), and stoma groups, 48 per cent (60 patients), P = 0.260. Likewise, 3-year disease-free survival did not differ statistically significant, SEMS 73 per cent (43 of 59 patients), stoma 65 per cent (62 of 95 patients), P = 0.32. In the SEMS group, 1.4 per cent (one patient) did not fulfil resection surgery compared to 8.8 per cent (11 patients) in the stoma group (P = 0.040). Postoperative complication and 30-day postoperative mortality rates did not differ, whereas the duration of hospital stay and proportion of permanent stoma were lower in the SEMS group. CONCLUSION: This nationwide registry-based study showed that long-term survival in patients with either SEMS or stoma as bridge to surgery in acute malignant large bowel obstruction were comparable. SEMS were associated with a lower rate of permanent stoma, higher rate of resection surgery and shorter duration of hospital stay.

Comparison of the prognosis of four different treatment strategies for acute left malignant colonic obstruction: a systematic review and network meta-analysis.

BACKGROUND: There is controversy regarding the efficacy of different treatment strategies for acute left malignant colonic obstruction. This study investigated the 5-year overall survival (OS) and disease-free survival (DFS) of several treatment strategies for acute left malignant colonic obstruction. METHODS: We searched for articles published in PubMed, Embase (Ovid), MEDLINE (Ovid), Web of Science, and Cochrane Library between January 1, 2000, and July 1, 2020. We screened out the literature comparing different treatment strategies. Evaluate the primary and secondary outcomes of different treatment strategies. The network meta-analysis summarizes the hazard ratio, odds ratio, mean difference, and its 95% confidence interval. RESULTS: The network meta-analysis involved 48 articles, including 8 (randomized controlled trials) RCTs and 40 non-RCTs. Primary outcomes: the 5-year overall survival (OS) and disease-free survival (DFS) of the CS-BTS strategy and the DS-BTS strategy were significantly better than those of the ES strategy, and the 5-year OS of the DS-BTS strategy was significantly better than that of CS-BTS. The long-term survival of TCT-BTS was not significantly different from those of CS-BTS and ES. SECONDARY OUTCOMES: compared with emergency resection (ER) strategies, colonic stent-bridge to surgery (CS-BTS) and transanal colorectal tube-bridge to surgery (TCT-BTS) strategies can significantly increase the primary anastomosis rate, CS-BTS and decompressing stoma-bridge to surgery (DS-BTS) strategies can significantly reduce mortality, and CS-BTS strategies can significantly reduce the permanent stoma rate. The hospital stay of DS-BTS is significantly longer than that of other strategies. There was no significant difference in the anastomotic leakage levels of several treatment strategies. CONCLUSION: Comprehensive literature research, we find that CS-BTS and DS-BTS strategies can bring better 5-year OS and DFS than ER. DS-BTS strategies have a better 5-year OS than CS-BTS strategies. Without considering the hospital stays, DS-BTS strategy is the best choice.

[Timing of surgery, intestinal ischemia and other real factors of mortality in acute adhesive small bowel obstruction: a multiple-center study]. / Faktory riska letal'nogo iskhoda pri ostroi spaechnoi tonkokishechnoi neprokhodimosti. Rezul'taty mnogotsentrovogo issledovaniya.

OBJECTIVE: To analyze the factors of mortality in patients with acute adhesive small bowel obstruction (ASBO). MATERIAL AND METHODS: A retrospective multiple-center study included 143 (85.6%) patients with ASBO 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: ASBO 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 ASBO and no obvious signs of strangulation due to less mortality.

Perforación y obstrucción colónica: conducta de los coloproctólogos latinoamericanos / Perforation and obstruction of the colon: behavior of the latin american colon and rectal surgeons

Resumen Objetivo: Conocer las diferentes conductas que realizan los cirujanos coloproctólogos latinoamericanos en relación con las urgencias colónicas. Materiales y Método: Estudio transversal, utilizando encuesta vía web con preguntas de selección múltiple. La encuesta fue enviada a las distintas Sociedades Coloproctológicas Latinoamericanas, así como a la Asociación Latinoamericana de Coloproctología (ALACP), para su distribución. La encuesta fue escrita en español neutro y traducida al portugués. Se utilizó análisis estadísticos descriptivos y analítico. Resultados: 441 encuestas respondidas completamente de 16 países diferentes. El 85% realiza resección y anastomosis sin ostomía de protección en obstrucciones de colon derecho. En las perforaciones del colon izquierdo, se realiza operación de Hartmann en el 63,3% de los casos que presentan peritonitis purulentas y en el 94,5% de las peritonitis fecaloideas. Discusión: En las obstrucciones colónicas, la resección con anastomosis primaria, es una conducta poco discutida en colon derecho, a diferencia de las obstrucciones del lado izquierdo, en donde realizar una operación de Hartmann es una conducta tan válida como la resección y anastomosis. En los cuadros de perforación, la decisión de resección y anastomosis primaria es multifactorial, tomando relevancia la estabilidad hemodinámica del paciente. En estos últimos casos, realizar una resección con ostomía, es la respuesta de gran parte de los encuestados. Conclusiones: Los resultados de cada situación, en su mayoría, presentan una tendencia clara hacia una conducta en particular; solo en el caso de obstrucción de colon izquierdo, se observan dos conductas (operación de Hartmann o anastomosis primaria) ambas validadas por la literatura internacional.

Objective: Learn about the different management options performed by latin american colon and rectal surgeons, in relation to colonic emergencies. Materials and Method: Cross-sectional study, using web survey with multiple-choice questions. The survey was sent to the different Latin America Coloproctological Societies, as well as to ALACP, for distribution. The survey was written in neutral Spanish and translated into Portuguese. Descriptive and analytical statistical analysis was used. Results: 441 complete surveys, from 16 different countries. 85% perform resection and anastomosis without diverting ostomy in obstructions of the right colon. In perforations of the left colon, Hartmann's procedure is performed in 63.3% of case with purulent peritonitis and in 94.5% of fecaloid peritonitis. Discussion: In colonic obstructions, resection with primary anastomosis, is little discussed behavior in the right colon, unlike obstructions on the left side, where performing a Hartmann operation is a behavior as valid as resection and anastomosis. In colonic perforation, the decision of resection and primary anastomosis is multifactorial, taking into account the hemodynamic stability of the patient. In the latter cases, performing an ostomy is the response of a large part of the surveyed. Conclusions: The results in each situation, for the most part, present a clear tendency towards a particular behavior; only in the case of left colon obstruction, two behaviors (Hartmann procedure or primary anastomosis) are both validated by international literature.

Factors impacting length of stay and survival in patients with advanced gynecologic malignancies and malignant bowel obstruction.

OBJECTIVES: Malignant bowel obstruction in patients with gynecologic malignancies can impose a large symptomatic burden. The objectives of this study were to identify factors associated with shorter length of hospital stay and overall survival in gynecologic oncology patients with malignant bowel obstructions. METHODS: A retrospective chart review was performed from December 2014 to March 2019 on patients admitted to a tertiary care center with a malignant bowel obstruction and advanced gynecologic malignancy. Data collection included patient and tumor characteristics, malignant bowel obstruction management (such as conservative management with bowel rest, nasogastric tube, pharmacotherapy or active intervention with surgery, chemotherapy, radiation, total parenteral nutrition or interventional stents), length of hospital stay, and survival outcomes. Statistical analysis included comparisons with Student's t-test and χ2 test, multivariable analysis, and survival analysis. RESULTS: A total of 107 patients with gynecologic cancer with malignant bowel obstruction were included. The majority of patients (63%, n=67) had ovarian cancer. The median length of hospital stay was 12 days (range 1-23), with a median overall survival after malignant bowel obstruction diagnosis of 7 months (range 0.1-64.1). Patients with active interventions had a longer length of stay compared with those with conservative management (13 vs 6 days, p<0.001). However, patients who received multiple active interventions had increased overall survival (9.1 vs 2.9 months, p=0.049). CONCLUSION: Patients who received multimodal treatment for malignant bowel obstruction had an increased length of stay and improvement in survival of over 6 months. This emphasizes the importance of a multidisciplinary approach to actively manage malignant bowel obstruction in advanced gynecologic cancer.

The neutrophil-to-lymphocyte ratio has feasible predictive value for hospital mortality in patients with small bowel obstruction in the emergency department.

PURPOSE: The neutrophil-to-lymphocyte ratio (NLR) is an effective predictor of mortality in patients with various conditions. To the best of our knowledge, there have been no previous studies on the NLR as a prognostic marker for small bowel obstruction (SBO), especially on admission to the emergency department (ED). METHODS: From January 2009 to December 2018, 653 patients diagnosed with SBO in the ED were included. Clinical and laboratory results, including the NLR, were evaluated as variables. The NLR was calculated as follows: NLR = absolute neutrophil count/absolute lymphocyte count. To evaluate SBO prognosis, data on hospital mortality and intensive care unit (ICU) admission were obtained. Multivariate logistic regression analysis and receiver operating characteristic (ROC) curve analysis were performed. RESULTS: Among the 653 patients, 16 (2.4%) died and 35 (5.3%) were admitted to the ICU during hospitalization. Multivariate logistic regression analysis demonstrated the NLR as an independent factor for predicting death (odds ratio, 1.3; p = 0.017]); however, there was no statistical significance for ICU admission (p = 0.94). The NLR showed good predictive performance for in-hospital mortality (area under the ROC curve, 0.768 [95% confidence interval, 0.620-0.861]; cut-off value, 10.6; p = 0.018). CONCLUSION: The NLR was positively associated with poor SBO prognosis. An elevated NLR was an independent predictive factor for in-hospital mortality in SBO patients. Emergency physicians should consider the NLR for SBO prognosis, and timely, aggressive, and prompt treatment is required, especially in patients with an NLR >10.6.

Does the diameter of colonic stent influence the outcomes in bridge-to-surgery patients with malignant large bowel obstruction?

PURPOSE: This study investigated the short- and long-term outcomes of 18- and 22-mm-diameter self-expandable metallic stent (SEMS) as a bridge to surgery (BTS) in patients with malignant large bowel obstruction (MLBO). METHODS: Sixty-nine pathological stage II and III colorectal cancer patients who underwent BTS were included in this multi-institutional retrospective study. Patients were divided into two groups regarding the diameter of SEMS: an 18-mm group (n = 30) and a 22-mm group (n = 39). RESULTS: There was no significant difference in the clinical success rate, but both of the two re-obstructions observed occurred in the 18-mm group. The 18-mm group showed a trend toward a higher incidence of overall postoperative complications (Clavien-Dindo grading ≥ II) than the 22-mm group (33.3% vs. 10.3%, P = 0.061). The 3-year disease-free and overall survival showed no significant differences between the 18- and 22-mm groups (78.2% vs. 68.8%, P = 0.753 and 92.8% vs. 82.1%, P = 0.471, respectively). CONCLUSION: SEMS of 18 and 22 mm diameter confer statistically equivalent short- and long-term outcomes as a BTS.

Hospital-level Variation in the Management and Outcomes of Patients With Adhesive Small Bowel Obstruction: A Population-Based Analysis.

OBJECTIVE: Determine the association between the rate of early operative management for adhesive small bowel obstruction (aSBO) at the hospital-level and the incidence of morbidity and mortality. BACKGROUND: Mounting evidence of the benefits of early operation in patients with aSBO has translated to both an increase in the proportion of patients treated operatively, and the proportion of patients who undergo early operative management. However, variation in practice remains. METHODS: We identified a population-based cohort of patients (18-80 years) who were admitted with their first episode of aSBO (2005-2014). The exposures of interest were hospital characteristics and the primary outcome measure was 30-day mortality. Hierarchical logistic regression models were used to evaluate hospital-level variation on 30-day mortality, serious complications, and bowel resection. RESULTS: A total of 27,026 patients were admitted to 122 hospitals, 23% (n = 6090) were managed operatively, 7% (n = 1845) had a serious complication, and 30-day mortality was 4.2% (n = 1146). The proportion of patients managed with early operation ranged from 0% to 33% [median 10% (interquartile range: 5%-14%)]. There was a 17% lower likelihood of 30-day mortality for every 10% increase in proportion of patients managed with an early operation at the hospital-level (odds ratio: 0.83, 95% confidence interval: 0.70-0.99). CONCLUSIONS: Hospitals with a higher proportion of aSBO patients treated with an early operation had a lower likelihood of serious complications, bowel resection, and death, independent of hospital type and volume of aSBO admissions. Early operative intervention rates likely are a proxy for additional structures and processes of care focused on aSBO patients that may facilitate patient selection.

Bowel obstruction as a serious complication of patients with femoral hernia.

PURPOSE: The implications of bowel obstruction occurring secondary to femoral hernia have not been discussed in the literature recently. Thus, we report our experience of treating patients with femoral hernias complicated by bowel obstruction versus patients with femoral hernias not complicated by bowel obstruction. METHODS: The subjects of this retrospective study were patients admitted to our hospital for the treatment of femoral hernias between 2016 and 2019. We used the Fisher and Student's T test to compare the preoperative characteristics, treatment, and outcomes of patients with bowel obstruction versus those without bowel obstruction. RESULTS: A total of 53 patients (mean age, 66.9 ± 15.1 years) were treated, 18 (33.9%) of whom underwent elective surgery and 35 (66%) of whom required emergency surgery (p = 0.001). The mean time between the development of symptoms and hospitalization was 4.5 ± 3.1 days for the patients with bowel obstruction and 1.6 ± 3.2 days for those without bowel obstruction (p = 0.001). The length of hospital stay was 11.1 ± 21.1 days for the patients with bowel obstruction and 1 ± 1.8 days for those without bowel obstruction (p = 0.028). Overall morbidity and mortality rates were 13.2% and 5.6%, respectively. CONCLUSION: Femoral hernias causing bowel obstruction are associated with greater time between the development of symptoms, hospitalization, and with a longer hospital stay.

Outcomes of self-expandable metal stent as bridge to surgery versus emergency surgery for left-sided obstructing colon cancer: A retrospective cohort study.

BACKGROUND: Long-term outcomes of self-expandable metal stents (SEMSs) as bridges to surgery versus emergency surgery in the treatment of left-sided obstructing colon cancer remain unclear. METHODS: Using a nationwide inpatient database in Japan, we performed one-to-one propensity score matching to compare overall survival, the stoma requirement, postoperative complications, and the length of stay between the SEMS and emergency surgery groups. RESULTS: Compared with the emergency surgery group, the SEMS group showed worse survival (hazard ratio, 1.80; 95% confidence interval, 1.07-3.01), a higher incidence of postoperative ileus (8% vs. 4%, P = 0.010), a longer postoperative length of stay (14 vs. 12 days, P < 0.001), and a lower stoma requirement (10% vs. 29%, P < 0.001). CONCLUSIONS: SEMSs as bridges to surgery are associated with significantly poorer overall survival, a higher incidence of postoperative ileus, a longer length of stay, and a lower stoma requirement than is emergency surgery.