Small Bowel Follow-Through: Treatment for Small Bowel Obstruction or Delaying the Inevitable?

BACKGROUND: Over 400,000 patients are admitted annually for small bowel obstruction (SBO), of which 20-40% require operative intervention, representing more than 2.3 billion dollars in healthcare expenses. Recurrence of SBO increases with a longer duration of follow-up with up to 15-20% recurrence rates within a five-year period. Small bowel follow-through (SBFT) consisting of serial X-rays with oral contrast has been shown to decrease overall length of stay (LOS) in patients with adhesive SBO. The aim of this study is to determine if SBFT administered to patients with SBO decreases 30-day and up to five-year readmission rates secondary to recurrent SBO. METHODS: The institutional review board (IRB) approved a single institution retrospective study from 2010 to 2020 that included a total of 742 patients. These patients were organized into groups of those who received the SBFT <24 hours after admission (n=40), those who received the SBFT >24 hours (n=198), and the third group of patients who did not receive the SBFT (n=658). Readmission rates <30 days, 70 years along with BMI <25, 25-29.9, 30-34.9, 35-39.9, >40, as well as the number of intraabdominal surgeries, gender, and need for operative intervention during the admission were evaluated to assess for any associations with recurrence. Readmission within 30 days and up to five years were compared. RESULTS: There were no significant differences in recurrence rates between groups with SBFT <24 hours (p=0.338) or SBFT >24 hours (p=0.889) when compared to the no SBFT group. There was nearly a 48% chance of readmission for another episode of an SBO for patients who did not undergo an operative intervention. While patients who underwent operative intervention had around a 29% chance of having a subsequent episode of an SBO. This is consistent with a statistically significant decrease in one-year (p=0.027) recurrences in patients who underwent operative intervention. CONCLUSION: There was no significant difference in recurrences with gender, most BMI groups, or in groups who underwent an SBFT. Operative intervention is associated with a statistically significant decrease in recurrence rates of SBO within one year of presentation.

Early Use of Small Bowel Follow Through Reduces Stay and Cost in Small Bowel Obstructions.

Background According to the Nationwide Inpatient Sample in 2011, nearly 1,500,000 admissions with over 300,000 laparotomies were performed for adhesion-related small bowel obstructions (SBOs). Small bowel follow through (SBFT) consists of serial X-rays with oral Gastrografin contrast that can diagnose obstructions requiring operative intervention. Furthermore, the contrast has a therapeutic osmotic effect which may promote transit and resolve an SBO. The aim of the study was to determine if early SBFT administration to patients with SBO decreases length of stay (LOS), hospital costs, and can identify patients who will fail non-operative management (NOM). Methodology This is a single institution retrospective study conducted from 2010 to 2019 with a total of 476 patients. We divided patients into three groups: SBFT within <24 hours of admission (n = 40), SBFT >24 hours after admission (n = 198), and did not receive SBFT (n = 238). We compared the overall LOS, hospital costs, and time from SBFT to the operating room using an analysis of variance. Results LOS significantly differed between groups with SBFT within ≤24 hours having an average LOS of 6.95 days compared to 10.65 days in the SBFT after >24 hours and 11.75 days in the no SBFT group (p = 0.005). Median time to the operating room in patients receiving SBFT was one day, which was significantly shorter than a median time of four days for no SBFT group (p = <0.05). Decreased LOS by 4.8 days equated to saving $8,657 per patient. Conclusions SBFT administered within 24 hours decreases LOS, overall costs, and time to operating room in patients who fail NOM.

Gallbladder Nonvisualization in Cholecystectomy: A Factor for Conversion.

BACKGROUND AND OBJECTIVES: Many risk factors have been identified in minimally invasive cholecystectomies that lead to higher complications and conversion rates. No study that we encountered looked at nonvisualization of the gallbladder (GB) during surgery as a risk factor. We hypothesized that nonvisualization was associated with an increased risk of complications and could be an early intraoperative identifier of a higher risk procedure. Recognizing this could allow surgeons to be aware of potential risks and to be more likely to convert to open for the safety of the patient. METHODS: We looked at minimally invasive cholecystectomies performed at our institution from January 2015 through April 2016 and had the performing resident fill out a survey after the surgery. Outcomes were conversion rates, intraoperative complications, and blood loss and were analyzed via Pearson χ2 test or Mann-Whitney U test. RESULTS: The primary outcome showed a conversion rate of 37% in nonvisualized GBs versus 0% in visualized (P = .001). Secondary outcomes showed significant differences in GB perforations (74% vs 13%, P = .001), omental vessel bleeding (16% vs. 0%, P = .005), and EBL (46 mL vs 29 mL, P = .001). CONCLUSIONS: Intraoperative nonvisualization of the GB after adequate positioning caused significantly increased risk of intraoperative complications and conversion. This knowledge could be useful during intraoperative assessment, to decide whether a case should be continued as a minimally invasive procedure or converted early to help reduce risk to the patient. Further randomized controlled studies should be performed to further demonstrate the value of this assessment.