Reconstructive operations for enteric and colonic fistulas: Low mortality and recurrence in a single-surgeon series with long follow-up.

BACKGROUND: The aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence. METHODS: Consecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas. RESULTS: Among the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not. CONCLUSIONS: With minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere.

Early postoperative small bowel obstruction: open vs laparoscopic.

BACKGROUND: The window for safe reoperation in early postoperative (<6 weeks) small bowel obstruction (ESBO) is short and intimately dependent on elapsed time from the initial operation. Laparoscopic procedures create fewer inflammatory changes than open laparotomies. We hypothesize that it is safer to reoperate for ESBO after laparoscopic procedures than open. METHODS: Review of patients who underwent re-exploration for ESBO from 2003 to 2009 was performed. Based on the initial operation, patients were classified as "open" or "laparoscopic." The Revised Accordion Severity Grading System was used to define complications as minor (1 to 2) or severe (3 to 6). RESULTS: There were 189 patients identified (age 55 years, 48% male): 130 open and 59 laparoscopic. Adhesive disease was more common (65% vs 42%, P < .01), while strictures were less frequent (5% vs 14% P = .03), in the open group. The open group had a greater rate of malignancy, days to re-exploration, and severity of complications. There was no difference in the rates of minor complications, enterotomy, and mortality. ESBO after laparoscopic surgery was more commonly caused by a focal source (85% vs 63%). Eighty-three patients (64 open, 19 laparoscopic) underwent re-exploration at or beyond 14 days. Within this subgroup, there were more severe complications (25% vs 5%) after open procedures with equivalent mortality (4% vs 0%). CONCLUSIONS: Laparoscopic approaches confer a lower rate of adhesive disease and severity of complications in early SBO as compared with open surgery even if performed after 2 weeks of index procedure.

Role of gastrografin challenge in early postoperative small bowel obstruction.

INTRODUCTION: Early small bowel obstruction following abdominal surgery presents a diagnostic and therapeutic challenge. Abdominal imaging using Gastrografin has been shown to have diagnostic and therapeutic properties when used in the setting of small bowel obstruction outside the early postoperative period (>6 weeks). We hypothesize that a GG challenge will reduce need for re-exploration. METHODS: Patients with early small bowel obstruction who underwent a Gastrografin challenge between 2010 and 2012 were case controlled, based on age ±5 years, sex, and operative approach to an equal number of patients that did not receive the challenge. RESULTS: One hundred sixteen patients received a Gastrografin challenge. There were 87 males in each group with an average age of 62 years. A laparoscopic approach in the index operation was done equally between groups (18 vs. 18 %). There was no difference between groups in operative re-exploration rates (14 vs. 10 %); however, hospital duration of stay was greater in patients who received Gastrografin challenge (17 vs. 13 days). Two in hospital deaths occurred, one in each group, both of infectious complications. CONCLUSION: Use of the Gastrografin challenge in the immediate postoperative period appeared to be safe. There was no difference, however, in the rate of re-exploration between groups.

Use of the Gastrografin challenge in patients with a history of abdominal or pelvic malignancy.

BACKGROUND: The Gastrografin (GG) challenge was developed to predict the need for operative management in patients with small bowel obstruction (SBO). Although clinical trials have demonstrated that it is an effective diagnostic and therapeutic modality, these studies excluded patients with a history of abdominal/pelvic malignancy. This study aims to examine the outcomes of the GG challenge for patients with a history of abdominal/pelvic malignancies. METHODS: Institutional review board approval was obtained to review retrospectively patients admitted with SBO in 3 separate categories: Group 1, patients presenting between 2010 and 2012 with SBO who received the GG challenge and had a concurrent history of abdominal or pelvic malignancy; group 2, patients presenting between 2010 and 2012 with SBO who underwent the GG challenge but did not have a concurrent history of abdominal or pelvic malignancy; and group 3, patients presenting between 2007 and 2010 (before our incorporation of the GG challenge protocol) with SBO and a concurrent history of abdominal or pelvic malignancy who did not receive GG . Two distinct comparisons were made. The first analysis was made between groups 1 and 2. The second comparison was performed comparing patients from groups 1 and 3. RESULTS: A total of 237 patients (74 group 1, 83 group 2, 80 group 3) were identified with a mean age of 69.1 years (range, 20-101); 115 were male (48%).There were no adverse events related to GG administration in our study. Analysis of groups 1 and 2 showed similar rates of exploration (25% vs 18%) and complications (32% vs 24%); however, mortality was greater among patients with history of malignancy at 12 months (26% vs 7%). Both groups had similar readmission rates for SBO, as well as exploration upon readmission. Analysis between groups 1 and 3 showed that the need for operative exploration at index admission was less in patients who underwent the GG challenge (26% vs 41%); however, hospital duration of stay was similar (8 vs 9 days). There was no difference in SBO recurrence at 12 months (28% vs 26%); however, mortality was significantly greater among patients not receiving GG (26% vs 41%). CONCLUSION: The GG challenge was safe and effective in patients presenting with SBO and a history of abdominal or pelvic malignancy. As a result, GG has the potential to improve these terminal patients' quality of life.

Enhancement of a small bowel obstruction model using the gastrografin® challenge test.

BACKGROUND: Based on a previous published data on small bowel obstruction (SBO), a management model for predicting the need for exploration has been adopted in our institution. In our model, patients presenting with three criteria-the history of obstipation, the presence of mesenteric edema, and the lack of small bowel fecalization on computed tomography (CT)-undergo exploration. Patients with two or less features were managed nonoperatively. An alternative tool for predicting need for operative intervention is Gastrografin (GG) challenge test. HYPOTHESIS: We hypothesized that the GG challenge test, when used in combination with our prior model, will decrease the rate of explorations in patients not meeting the criteria for immediate operation. METHODS: An approval from IRB was obtained to review patients admitted with a diagnosis of SBO from November 2010 to September 2011. All patients presenting with signs of ischemia, patients with all three model criteria defined previously, and those who had an abdominal operation within 6 weeks of diagnosis were excluded. All patients had an abdominal/pelvic CT and GG challenge at the time of diagnosis. Patients were compared to historic controls managed without the GG challenge (from July to December 2009). Successful GG challenge was defined as the presence of contrast in the colon after a follow-up film or a bowel movement. Data were presented as medians or percentages; significance was considered at p < 0.05. RESULTS: One hundred and twenty-five patients with a diagnosis of small bowel obstruction were identified wherein 47 % were males. Fifty-three received a GG challenge (study), and 72 did not have a GG challenge (historic). There was no difference in age (70 vs 65 years), history of prior SBO (51 vs 49 %), history of diabetes mellitus (21 vs 18 %), history of malignancy (32 vs 39 %), or cardiac disease (30 vs 39 %). Both groups had similar number of previous abdominal operations (two vs two). The presence of mesenteric edema (68 vs 75 %), the lack of small bowel fecalization (47 vs 46 %), and a history of obstipation (25 vs 24 %) were similar in both groups. Patients in the study group had a lesser rate of abdominal exploration (25 vs 42 %, p = 0.05) and fewer complications (13 vs 31 %, p = 0.02) compared to the historic control group. There was equivalent incidence of ischemic bowel (4 vs 7 %), duration of hospital stay (4 vs 7 days), duration from admission to operation (2 vs 3 days), and mortality (8 vs 6 %); 44 patients had a successful GG challenge with nine failures. There was a greater rate of exploration in patients with a failed challenge compared to those with a successful challenge (89 vs 11 %, p < 0.01). CONCLUSION: The use of the GG challenge enhanced the SBO prediction model by decreasing the need for exploration in patients not meeting the criteria for immediate operation. Patients who failed the GG challenge test were much more likely to undergo an exploration.

Duty hour recommendations and implications for meeting the ACGME core competencies: views of residency directors.

OBJECTIVE: To describe the views of residency program directors regarding the effect of the 2010 duty hour recommendations on the 6 core competencies of graduate medical education. METHODS: US residency program directors in internal medicine, pediatrics, and general surgery were e-mailed a survey from July 8 through July 20, 2010, after the 2010 Accreditation Council for Graduate Medical Education (ACGME) duty hour recommendations were published. Directors were asked to rate the implications of the new recommendations for the 6 ACGME core competencies as well as for continuity of inpatient care and resident fatigue. RESULTS: Of 719 eligible program directors, 464 (65%) responded. Most program directors believe that the new ACGME recommendations will decrease residents' continuity with hospitalized patients (404/464 [87%]) and will not change (303/464 [65%]) or will increase (26/464 [6%]) resident fatigue. Additionally, most program directors (249-363/464 [53%-78%]) believe that the new duty hour restrictions will decrease residents' ability to develop competency in 5 of the 6 core areas. Surgery directors were more likely than internal medicine directors to believe that the ACGME recommendations will decrease residents' competency in patient care (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.5-6.3), medical knowledge (OR, 1.9; 95% CI, 1.2-3.2), practice-based learning and improvement (OR, 2.7; 95% CI, 1.7-4.4), interpersonal and communication skills (OR, 1.9; 95% CI, 1.2-3.0), and professionalism (OR, 2.5; 95% CI, 1.5-4.0). CONCLUSION: Residency program directors' reactions to ACGME duty hour recommendations demonstrate a marked degree of concern about educating a competent generation of future physicians in the face of increasing duty hour standards and regulation.

Small bowel obstruction-who needs an operation? A multivariate prediction model.

BACKGROUND: Proper management of small bowel obstruction (SBO) requires a methodology to prevent nontherapeutic laparotomy while minimizing the chance of overlooking strangulation obstruction causing intestinal ischemia. Our aim was to identify preoperative risk factors associated with strangulating SBO and to develop a model to predict the need for operative intervention in the presence of an SBO. Our hypothesis was that free intraperitoneal fluid on computed tomography (CT) is associated with the presence of bowel ischemia and need for exploration. METHODS: We reviewed 100 consecutive patients with SBO, all of whom had undergone CT that was reviewed by a radiologist blinded to outcome. The need for operative management was confirmed retrospectively by four surgeons based on operative findings and the patient's clinical course. RESULTS: Patients were divided into two groups: group 1, who required operative management on retrospective review, and group 2 who did not. Four patients who were treated nonoperatively had ischemia or died of malignant SBO and were then included in group 1; two patients who had a nontherapeutic exploration were included in group 2. On univariate analysis, the need for exploration (n = 48) was associated (p < 0.05) with a history of malignancy (29% vs. 12%), vomiting (85% vs. 63%), and CT findings of either free intraperitoneal fluid (67% vs. 31%), mesenteric edema (67% vs. 37%), mesenteric vascular engorgement (85% vs. 67%), small bowel wall thickening (44% vs. 25%) or absence of the "small bowel feces sign" (so-called fecalization) (10% vs. 29%). Ischemia (n = 11) was associated (p < 0.05 each) with peritonitis (36% vs. 1%), free intraperitoneal fluid (82% vs. 44%), serum lactate concentration (2.7 +/- 1.6 vs. 1.3 +/- 0.6 mmol/l), mesenteric edema (91% vs. 46%), closed loop obstruction (27% vs. 2%), pneumatosis intestinalis (18% vs. 0%), and portal venous gas (18% vs. 0%). On multivariate analysis, free intraperitoneal fluid [odds ratio (OR) 3.80, 95% confidence interval (CI) 1.5-9.9], mesenteric edema (OR 3.59, 95% CI 1.3-9.6), lack of the "small bowel feces sign" (OR 0.19, 95% CI 0.05-0.68), and a history of vomiting (OR 4.67, 95% CI 1.5-14.4) were independent predictors of the need for operative exploration (p < 0.05 each). The combination of vomiting, no "small bowel feces sign," free intraperitoneal fluid, and mesenteric edema had a sensitivity of 96%, and a positive predictive value of 90% (OR 16.4, 95% CI 3.6-75.4) for requiring exploration. CONCLUSION: Clinical, laboratory, and radiographic factors should all be considered when making a decision about treatment of SBO. The four clinical features-intraperitoneal free fluid, mesenteric edema, lack of the "small bowel feces sign," history of vomiting-are predictive of requiring operative intervention during the patient's hospital stay and should be factored strongly into the decision-making algorithm for operative versus nonoperative treatment.