Primary Surgery for Malignant Large Bowel Obstruction: Postoperative Nasogastric Tube Reinsertion is Not Mandatory.

BACKGROUND: Malignant large bowel obstructions frequently require emergency surgery. Compliance with enhanced recovery after surgery programmes is significantly reduced due to non-removal of the nasogastric tube in the postoperative period. The first aim of the present study was to research factors associated with the failure of immediate nasogastric tube removal in patients who had undergone emergency surgery for malignant large bowel obstruction. The second aim was to assess the morbidity linked to nasogastric tube reinsertion. METHODS: This retrospective and monocentric study included all consecutive patients admitted for acute malignant large bowel obstruction who underwent emergency surgery. Patients who were not primarily operated on were excluded (n = 178; 69.3%). The group of patients requiring nasogastric tube (NGT) reinsertion was compared with the group that did not require NGT reinsertion. RESULTS: Seventy-nine patients underwent emergency surgery, of which 18 (22.8%) required nasogastric tube reinsertion. There was no difference between the two groups with regard to (a) immediate nasogastric tube removal (p = 0.87) and (b) inclusion in an enhanced recovery programme (p = 0.75). However, preoperative small bowel dilatation was associated with a reduction in the need for NGT reinsertion (p = 0.04). A left-sided tumour was also associated with the need for NGT reinsertion in uni- (p = 0.034) and multivariate analysis (OR = 8; p < 0.05). Surgical access and procedure were not significantly associated with NGT reinsertion. The postoperative course influenced NGT reinsertion, which was significantly associated with postoperative ileus (OR = 4; p < 0.05) and postoperative morbidity (OR = 4; p < 0.05). Morbidity was not linked to nasogastric tube removal. CONCLUSION: Nasogastric tube reinsertion was not affected by immediate removal of the tube. Left-sided tumours and patients at risk of postoperative ileus should be managed with caution. Immediate nasogastric tube removal is not contraindicated in the case of large bowel obstruction because it is not associated with a higher risk of NGT reinsertion.

Failure of Conservative Treatment of Acute Diverticulitis with Extradigestive Air.

BACKGROUND: Medical management for perforated diverticulitis without abscess or peritonitis (PDwAP) has a success rate of 40-70%. Identifying patients with a risk of medical treatment failure would improve outcomes. The aim of this study was to identify the risk factors for failure of medical treatment in patients admitted with PDwAP. METHODS: This multicenter retrospective observational study included all consecutive patients admitted for PDwAP and not surgically treated over a 7-year period. Peritonitis classified on the Hinchey scale was excluded. Potential clinical, biological and radiological risk factors for medical treatment failure were collected and compared between the group of patient with a failure of medical treatment (F) and the group in which treatment did not fail. Data were collected at referral. RESULTS: Ninety-one patients were included, and 29 had a failure of treatment (31.9%). The median heart rate was different between the two groups (p < 0.001), at approximately 100/min in the F group. A blood level of C-reactive protein (CRP) ≥150 mg/mL was associated with a higher rate of failure (p = 0.021), but it was not confirmed in multivariate analysis. Pneumoperitoneum ≥5 mm and intraperitoneal liquid located in the pouch of Douglas were more likely to be present in the F group (respectively, p = 0.001 and p < 0.001). A multivariate analysis showed independent risk factors as being the highest pneumoperitoneum diameter >5 mm (OR 5.193; p = 0.015) and peritoneal fluid location in the pouch of Douglas (OR 4.103; p = 0.036). CONCLUSION: The severity of sepsis (tachycardia and CRP ≥150 mg/mL) and of imaging signs (pneumoperitoneum ≥5 mm and peritoneal fluid in the pouch of Douglas) were risk factors for medical treatment failure of PDwAP requiring special supervision so as not to lose time in undertaking surgical management.

Alterations of digestive motility after bariatric surgery.

Bariatric surgery can induce changes in digestive motility that are de novo or secondary to an improvement or aggravation of previous disorders due to obesity. Alterations of digestive motility are frequently part of the mechanism of action and a result of surgery. They are not rare and they are not always associated with an increase in weight loss but can lead to the negative consequences on quality of life, which are more or less reversible as a real surgical complication. Knowledge of these complications has become essential, especially in this period when bariatric surgery often concerns patients who have already undergone an operation. Thus, the changes in digestive motility after bariatric surgery and the complications that may result from them must be known and considered to adapt surgical techniques to each patient, both in the case of a first intervention and in the case of a reoperation, which is becoming more and more frequent. The objective of this review is to synthesize alterations of esophageal and gastro-intestinal motility secondary to bariatric surgical procedures.

Postoperative ileus: Pathophysiology, incidence, and prevention.

Postoperative ileus (POI) is a major focus of concern for surgeons because it increases duration of hospitalization, cost of care, and postoperative morbidity. The definition of POI is relatively consensual albeit with a variable definition of interval to resolution ranging from 2 to 7 days for different authors. This variation, however, leads to non-reproducibility of studies and difficulties in interpreting the results. Certain risk factors for POI, such as male gender, advanced age and major blood loss, have been repeatedly described in the literature. Understanding of the pathophysiology of POI has helped combat and prevent its occurrence. But despite preventive and therapeutic efforts arising from such knowledge, 10 to 30% of patients still develop POI after abdominal surgery. In France, pharmacological prevention is limited by the unavailability of effective drugs. Perioperative nutrition is very important, as well as limitation of preoperative fasting to 6 hours for solid food and 2 hours for liquids, and virtually no fasting in the postoperative period. Coffee and chewing gum also play a preventive role for POI. The advent of laparoscopy has led to a significant improvement in the recovery of gastrointestinal function. Enhanced recovery programs, grouping together all measures for prevention or cure of POI by addressing the mechanisms of POI, has reduced the duration of hospitalization, morbidity and interval to resumption of transit.