Mortality risk of patients with intestinal obstruction.

BACKGROUND: Intestinal obstruction represents a severe intestinal disease associated with higher mortality rates. However, the determinants of mortality in patients with intestinal obstruction remain inadequately understood. This study sought to elucidate the potential risk factors associated with mortality in the context of intestinal obstruction during the COVID-19 pandemic. METHODS: A retrospective analysis was performed on a cohort of 227 patients diagnosed with intestinal obstruction at the First Hospital of Hebei Medical University, spanning the period from September 7, 2022, to January 7, 2023. The primary endpoint of the study was mortality within four weeks following discharge. Univariate and multivariable logistic regression models were utilized to evaluate the risk factors associated with mortality outcomes. RESULTS: A cohort of 227 patients diagnosed with intestinal obstruction (median age, 59.02 years [IQR, 48.95-70.85 years]) was included in our study. Malignant bowel obstruction (MBO) and COVID-19 were identified as independent risk factors for mortality among these patients. Notably, the mortality rate increased significantly to 38.46% when MBO was concomitant with COVID-19. Furthermore, postoperative pulmonary complications (PPC) (OR, 54.21 [death]; 95% CI, 3.17-926.31), gastric cancer (OR, 9.71 [death]; 95% CI, 1.38-68.18), VTE (Caprini Score ≥ 5) (OR, 7.64 [death]; 95% CI, 1.37-42.51), and COVID-19 (OR, 5.72 [death]; 95% CI, 1.01-32.29) were all determined to be independent risk factors for postoperative mortality. Additionally, gastric cancer could have emerged as one of the most severe risk factors for mortality in individuals with intestinal obstruction within the cohort of cancer patients, of which gastric cancer exhibited higher mortality rates compared to individuals with other forms of cancer. CONCLUSION: The study identifies MBO, gastric cancer, COVID-19, PPC, and VTE as potential risk factors for mortality in cases of intestinal obstruction. These findings highlight the necessity for continuous monitoring of indicators related to these mortality risk factors and their associated complications, thereby offering valuable insights for the management and treatment of intestinal obstruction.

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.

Outcomes of patients admitted with malignant small bowel obstruction: a subgroup multicentre observational cohort analysis.

INTRODUCTION AND PURPOSE OF THE STUDY: Small bowel obstruction (SBO) accounts for a substantial proportion of emergency surgical admissions. Malignancy is a common cause of obstruction, either due to a primary tumour or intra-abdominal metastases. However, little is known regarding the current treatment or outcomes of patients with malignant SBO. This study aimed to characterise the treatment of malignant SBO and identify areas for potential improvement and compare overall survival of patients with malignant SBO to patients with non-malignant SBO. MATERIALS AND METHODS: This was a subgroup analysis of a multicentre observational study of patients admitted with SBO. Details regarding these patients' diagnoses, treatments, and outcomes up to 1-year after admission were recorded. The primary outcome was overall survival in patients with malignant SBO. RESULTS: A total of 316 patients with small bowel obstruction were included, of whom 33 (10.4%) had malignant SBO. Out of the 33 patients with malignant SBO, 20 patients (60.6%) were treated with palliative intent although only 7 patients were seen by a palliative team during admission. Nutritional assessments were performed on 12 patients, and 11 of these patients received parenteral nutrition. 23 patients underwent surgery, with the most common surgical interventions being loop ileostomies (9 patients) and gastrointestinal bypasses (9 patients). 4 patients underwent right hemicolectomies, with a primary anastomosis formed and 1 patient had a right hemicolectomy with a terminal ileostomy. Median survival was 114 days, and no difference was seen in survival between patients treated with or without palliative intent. CONCLUSION: Malignant SBO is associated with significant risks of short-term complications and a poor prognosis. Consideration should be given to the early involvement of senior decision-makers upon patient admission is essential for optimal management and setting expectation for a realistic outcome.

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.

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).

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.

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.

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.

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.

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.

[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.

Decompressing Stoma a s Bridge to Elective Surgery is an Effective Strategy for Left-sided Obstructive Colon Cancer: A National, Propensity-score Matched Study.

OBJECTIVE: The purpose of this population-based study was to compare decompressing stoma (DS) as bridge to surgery (BTS) with emergency resection (ER) for left-sided obstructive colon cancer (LSOCC) using propensity-score matching. SUMMARY BACKGROUND DATA: Recently, an increased use of DS as BTS for LSOCC has been observed in the Netherlands. Unfortunately, good quality comparative analyses with ER are scarce. METHODS: Patients diagnosed with nonlocally advanced LSOCC between 2009 and 2016 in 75 Dutch hospitals, who underwent DS or ER in the curative setting, were propensity-score matched in a 1:2 ratio. The primary outcome measure was 90-day mortality, and main secondary outcomes were 3-year overall survival and permanent stoma rate. RESULTS: Of 2048 eligible patients, 236 patients who underwent DS were matched with 472 patients undergoing ER. After DS, more laparoscopic resections were performed (56.8% vs 9.2%, P < 0.001) and more primary anastomoses were constructed (88.5% vs 40.7%, P < 0.001). DS resulted in significantly lower 90-day mortality compared to ER (1.7% vs 7.2%, P = 0.006), and this effect could be mainly attributed to the subgroup of patients over 70 years (3.5% vs 13.7%, P = 0.027). Patients treated with DS as BTS had better 3-year overall survival (79.4% vs 73.3%, hazard ratio 0.36, 95% confidence interval 0.20-0.65) and fewer permanent stomas (23.4% vs 42.4%, P < 0.001). CONCLUSIONS: In this nationwide propensity-score matched study, DS as a BTS for LSOCC was associated with lower 90-day mortality and better 3-year overall survival compared to ER, especially in patients over 70 years of age.

Supported self-management as a model for end-of-life care in the setting of malignant bowel obstruction: A qualitative study.

OBJECTIVE: Women with advanced gynecologic cancer and malignant bowel obstruction (MBO) undergo repeated hospitalizations, experience feelings of isolation and abandonment, and often die in acute settings. Innovative outpatient models of care are needed to address the unmet needs of this population at the end-of-life. We implemented a novel supported self-management (SMS) program focused on increasing patients' skill and confidence in managing MBO proactively in the ambulatory setting. METHODS: We performed a qualitative descriptive study embedded in a prospective single-arm evaluative trial (Clinicaltrials.gov ID: NCT03260647) to understand the impact of this program on patients' sense of support, degree of distress, quality of care, and capacity to self-manage. Semi-structured interviews were completed and analysed using the Chronic Care Model as a theoretical framework. Data saturation was confirmed after 15 interviews. RESULTS: Fifteen patients (age range: 47-82) with diagnoses of advanced ovarian, endometrial, and cervical cancer were interviewed; 10 had died by end of follow-up, with a median interval from interview to death of 5 months. Patients were able to self-manage the: (i) medical aspects; (ii) psychological consequences, and (iii) changes in life roles and expectations resulting from their condition. Patients felt greatly supported, less isolated, and secure in their knowledge and ability to access care due to SMS. While patients understood their disease was not curative they did not fully appreciate that MBO signalled a significantly poorer prognosis. CONCLUSION: Outpatient SMS interventions can be successfully implemented even for rapidly fatal conditions at the end-of-life and offer significant benefit to gynecologic cancer patients with MBO. Counselling should focus on the specific trajectory of MBO, and early palliative care referrals should be standard practice.

Are There Variations in Mortality From Diverticular Disease By Sex?

BACKGROUND: Previous data reveal that females account for a disproportionate majority of all patients diagnosed with diverticulitis. OBJECTIVE: This study analyzed the variation in mortality from diverticular disease by sex. DESIGN: This was a nationwide retrospective cohort study. SETTINGS: Data were obtained from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research national registry. PATIENTS: All citizens of the United States who died from an underlying cause of death of diverticulitis between January 1999 and December 2016 were included. MAIN OUTCOME MEASURES: The primary outcome addressed was overall mortality rate of diverticulitis by sex. Secondary outcomes included pattern variances in demographics and secondary causes of death. RESULTS: During the study period, 55,096 patients (0.12%) died with an underlying cause of death of diverticulitis from a total of 44,915,066 deaths. Compared with other causes, females were disproportionally more likely to die from diverticulitis than males (0.17% females vs 0.08% males; p < 0.001). Age-adjusted incidence of death was higher for females compared with males. Female patients were less likely to die within the hospital compared with males (OR = 0.72 (95% CI, 0.69-0.75); p < 0.001). Conversely, female patients were more likely to die either at nursing homes or hospice facilities (OR = 1.64 (95% CI, 1.55-1.73); p < 0.001). In addition, females with an underlying cause of death of diverticulitis were less likely to have a surgical complication as their secondary cause of death (OR = 0.72 (95% CI, 0.66-0.78); p < 0.001) but more likely to have nonsurgical complications related to diverticulitis such as sepsis (OR = 1.04 (95% CI, 1.01-1.05); p < 0.03), nonsurgical GI disorders such as obstruction (OR = 1.16 (95% CI, 1.09-1.24); p < 0.001), or chronic pelvic fistulizing disease (OR = 1.43 (95% CI, 1.23-1.66); p < 0.001). LIMITATIONS: The study was limited by a lack of more specific clinical data. CONCLUSIONS: Females have a higher incidence of diverticular disease mortality. Their deaths are more commonly secondary to nonsurgical infections, obstruction, or pelvic fistulae. Female patients represent a particularly vulnerable population that may benefit from more intensive diverticulitis evaluation. See Video Abstract at http://links.lww.com/DCR/B257. ¿EXISTEN VARIACIONES EN LA MORTALIDAD POR ENFERMEDAD DIVERTICULAR POR GÉNERO?: Los datos anteriores revelan que las mujeres representan una mayoría desproporcionada de todos los pacientes diagnosticados con diverticulitis.Este estudio analizó la variación en la mortalidad por enfermedad diverticular por género.Estudio de cohorte retrospectivo a nivel nacional.Los datos se obtuvieron del registro nacional WONDER del Centro de Control de Enfermedades.Se incluyeron todos los ciudadanos de los Estados Unidos que murieron por una causa subyacente de muerte (UCOD por sus siglas en inglés) de diverticulitis del 1 / 1999-12 / 2016.El resultado primario abordado fue la tasa de mortalidad general de la diverticulitis por género. Los resultados secundarios incluyeron variaciones de patrones en la demografía y causas secundarias de muerte.Falta de datos clínicos más específicos.Durante el período de estudio, 55.096 pacientes (0,12%) murieron con un UCOD de diverticulitis de un total de 44.915.066 muertes. En comparación con otras causas, las mujeres tenían una probabilidad desproporcionadamente mayor de morir de diverticulitis que los hombres (0.17% F vs. 0.08% M, p <0.001). La incidencia de muerte ajustada por edad fue mayor para las mujeres que para los hombres. Las pacientes femeninas tenían menos probabilidades de morir en el hospital en comparación con los hombres (OR 0.72, IC 0.69-0.75, p <0.001). Por el contrario, las pacientes femeninas tenían más probabilidades de morir en asilos de ancianos o en centros de cuidados paliativos (OR 1.64, IC 1.55-1.73, p <0.001). Además, las mujeres con una UCOD de diverticulitis tenían menos probabilidades de tener una complicación quirúrgica como causa secundaria de muerte (OR 0.72, CI 0.66-0.78, p <0.001) pero más probabilidades de tener complicaciones no quirúrgicas relacionadas con la diverticulitis, como sepsis (OR 1.04, CI 1.01-1.05, p <0.03), trastornos gastrointestinales no quirúrgicos como obstrucción (OR 1.16, CI 1.09-1.24, p <0.001), o enfermedad fistulizante pélvica crónica (OR 1.43, CI 1.23-1.66, p <0,001).Las mujeres tienen una mayor incidencia de mortalidad por enfermedad diverticular. Sus muertes son más comúnmente secundarias a infecciones no quirúrgicas, obstrucción o fístulas pélvicas. Las pacientes femeninas representan una población particularmente vulnerable que puede beneficiarse de una evaluación más intensiva de diverticulitis. Consulte Video Resumen en http://links.lww.com/DCR/B257.

The prognostic value of the prognostic nutritional index and inflammation-based markers in obstructive colorectal cancer.

PURPOSE: Inflammation-based markers predict long-term outcomes of various malignancies. We investigated the relationship between these markers and the long-term survival in obstructive colorectal cancer (OCRC) patients with self-expandable metallic colonic stents (SEMSs) who subsequently received curative surgery. METHODS: We retrospectively analyzed 72 consecutive pathological stage II and III OCRC patients between 2013 and 2019. The prognostic significance of the prognostic nutritional index (PNI), neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), and platelet-lymphocyte ratio (PLR) was evaluated. RESULTS: The overall survival (OS), cancer-specific survival, and disease-free survival (DFS) were significantly shorter in the PNI < 35 group than in the PNI ≥ 35 group (p = 0.006, p < 0.001, and p = 0.003, respectively), and multivariate analyses revealed the PNI to be the only inflammation-based marker independently associated with the survival. A PNI < 35 was significantly associated with an elevated CA 19-9 level (p = 0.04) and longer postoperative hospital stay (p = 0.03). Adjuvant chemotherapy was also significantly associated with the OS (p = 0.040) and DFS (p = 0.011) in multivariate analyses. CONCLUSION: The results showed that the PNI was a potent prognostic indicator. For OCRC patients, both systemic inflammation and the nutrition status seem to be important for predicting the prognosis, and administering adjuvant chemotherapy was very important.

Oncologic Outcomes of Self-Expandable Metallic Stent as a Bridge to Surgery and Safety and Feasibility of Minimally Invasive Surgery for Acute Malignant Colonic Obstruction.

BACKGROUND: Although self-expandable metal stents (SEMS) are widely used as a bridge to surgery (BTS) in patients with malignant colorectal cancer obstruction, there has been some debate about their effect on long-term oncological outcomes. Furthermore, data on the safety and feasibility of minimally invasive surgery (MIS) combined with stent placement are scarce. We aimed to determine the long-term oncological outcomes of SEMS as a BTS, and the short-term outcomes of SEMS used with minimally invasive colorectal surgery. METHODS: Data from patients who were admitted with malignant obstructing colon cancer between January 2006 and December 2015 were retrospectively reviewed; 71 patients underwent direct surgery and 182 patients underwent SEMS placement as a BTS. Long-term and short-term outcomes of the groups were compared. In a subgroup analysis of the BTS group, the short-term outcomes of conventional open surgery and MIS were compared. RESULTS: There were no differences in long-term oncologic outcomes between groups. The primary anastomosis rate was higher in the stent group than in the direct surgery group. In the stent group, postoperative complication rates were lower in the minimally invasive group than in the open surgery group. Time to flatus and time to soft diet resumption were shorter in the minimally invasive group, as was length of hospital stay. CONCLUSIONS: Elective surgery after stent insertion does not adversely affect long-term oncologic outcomes. Furthermore, MIS combined with stent insertion for malignant colonic obstruction is safe and feasible.

Obstruction-Free Survival Following Operative Intervention for Malignant Bowel Obstruction in Appendiceal Cancer.

BACKGROUND: Patients with peritoneal metastases from appendiceal cancer are at high risk of malignant bowel obstruction (MBO), which is associated with significant morbidity and mortality. There are no definitive treatment guidelines regarding operative intervention for MBO. We sought to evaluate the efficacy and safety of operative intervention in this population. METHODS: We identified patients with peritoneal metastases from appendiceal cancer who underwent surgery for MBO at our institution between 2011 and 2018. Baseline characteristics, postoperative complications, and follow-up data were collected. The primary endpoint was obstruction-free survival (OFS). Other endpoints were postoperative recovery of bowel function, 60-day Clavien-Dindo (CD) morbidity, and overall survival (OS). RESULTS: Twenty-six patients underwent operative treatment for MBO, of whom 14 had high-grade (HG) histology and 12 had low-grade (LG) histology. Seven (25.9%) patients had severe (CD grade 3 or higher) 60-day complications, including one (3.8%) postoperative death. All remaining patients had return of bowel function and resumed oral intake during hospitalization. Six (23.1%) patients had repeat admissions for MBO after surgery. Median OFS was 17.0 months (95% confidence interval [CI] 2.3-31.8), and median OS was 18.5 months (95% CI 3.6-33.3) following surgery. CONCLUSION: In this carefully selected group of patients with peritoneal metastases from appendiceal cancer, surgery for MBO provided durable palliation with acceptable morbidity.

Can the Laparoscopic Approach for Adhesive Small Bowel Obstruction be Used in Octogenarians? An Observational Study Using ACS NSQIP.

BACKGROUND: With the population of octogenarians projected to increase fourfold by 2050, we sought to compare outcomes of laparoscopic versus open approach in octogenarians requiring surgery for adhesive small bowel obstruction (SBO). METHODS/MATERIALS AND METHODS: Using 2006-2015 American College of Surgeons National Surgical Quality Improvement Project, we identified patients aged ≥80 y who underwent emergency surgery within 1 d of admission for SBO. Risk variables of interest included age, sex, race, body mass index, preoperative sepsis, and American Society of Anesthesiologists (ASA) classification. Outcomes included length of stay, mortality, and pneumonia. Univariable and multivariable analyses were performed. RESULTS: Eight hundred fifty-six patients were identified. Six hundred ninety-nine (81.7%) underwent laparotomy; 157 (18.3%) underwent laparoscopy. Twenty-four (15.3%) of laparoscopic cases were converted. There was no difference between the open and laparoscopic groups in age, and race, preoperative albumin, or preoperative sepsis. The open group had higher rates of totally dependent functional status, congestive heart failure, chronic obstructive pulmonary disease, and higher ASA class. There was no difference in operative time. Laparoscopy was associated with shorter length of stay. The open approach showed higher rates of postoperative pneumonia, myocardial infarct, and mortality. Multivariable analysis showed increased age, functional status, preoperative albumin, and ASA class associated with mortality. The operative approach was not associated with mortality. Postoperative pneumonia was associated with male sex and open approach. CONCLUSIONS: Age, preoperative functional status, low preoperative albumin, and ASA classes IV and V were associated with mortality, while the open approach and male sex were associated with postoperative pneumonia. Octogenarians who present with SBO due to adhesive disease may benefit from an initial laparoscopic exploration. Further prospective studies are warranted.

Colonic stenting as a bridge to surgery in malignant large bowel obstruction: oncological outcomes.

INTRODUCTION: Stenting of obstructing colorectal cancers obviates the need for emergency surgery, reducing initial morbidity and mortality rate associated with emergency surgery and facilitates full staging of the neoplastic process with an opportunity to optimize the patient for surgery. Some recent publications have suggested however that this approach may be associated with higher local recurrence rates. We examined our outcomes following colonic stenting as a bridge to resection. METHODS: A database was reviewed (2006-2018) of patients presenting with acute colorectal obstruction that proceeded to endoscopic stenting. We assessed the bridge to surgery strategy, its success, complication rate, and impact on recurrence and survival. RESULTS: Of a total of 103 patients who presented with acute malignant large bowel obstruction over this time period, 26 patients had potentially curable disease at presentation and underwent stenting as a bridge to surgery. The technical success rate for stenting in those managed as a bridge to surgery was 92% (n = 24/26) with 7.69% (n = 2/26) having a complication. There was one stent-related perforation. Median follow-up of this cohort was 31 months, with a 5-year overall survival of 53.5%. CONCLUSION: Colorectal stenting as a bridge to resection is a successful management strategy for those presenting with obstructing colorectal obstruction. Selective use is associated with lower rates of stoma formation, greater rates of laparoscopic resections with low complication rates, and acceptable oncological outcomes.