Determining the need for surgery in small bowel obstructions based on clinical, laboratory, and radiological parameters.

OBJECTIVE: Small bowel obstruction (SBO) is a common and important surgical emergency. Our aim in this study is to describe the clinical, laboratory, and computed tomography (CT) findings to facilitate the objective identification of SBO patients in need of operative treatment in this patient population. METHODS: This retrospective study included 340 patients hospitalized due to a preliminary diagnosis of ileus. Retrieved data of patients included age, gender, comorbidities, previous hospitalization due to ileus, surgical history, physical examination findings, complete blood count and biochemistry test results, and CT findings at admission. RESULTS: The study included 180 (52.9%) male and 160 (47.1%) female patients. Treatment was conservative in 216 patients and surgery in 124 patients. Of the patients included in the study, 36.4% needed surgery. Of the female patients, 38.90% received conservative treatment and 61.30% underwent surgery. Adhesions were the most common cause of obstruction in operated patients (43.50%). CONCLUSION: We have found that female gender, vomiting, guarding, rebound, C-reactive protein levels above 75 mg/L, increased bowel diameter, and a transition zone on CT images indicate a strong need for surgery, but a history of previous hospitalization for ileus may show that surgery may not be the best option.

OBJETIVO: Describir los hallazgos clínicos, de laboratorio y de tomografía computarizada (TC) para facilitar la identificación objetiva de los pacientes con obstrucción del intestino delgado que necesitan tratamiento quirúrgico. MÉTODO: Este estudio incluyó 340 pacientes. Los datos obtenidos fueron edad, sexo, comorbilidad, hospitalización previa debida a íleo, historia quirúrgica, hallazgos de la exploración física, hemograma completo y resultados de las pruebas bioquímicas, y hallazgos de la TC al ingreso. RESULTADOS: El estudio incluyó 180 (52.9%) varones y 160 (47.1%) mujeres. El tratamiento fue conservador en 216 pacientes y quirúrgico en 124 pacientes. De los pacientes incluidos en el estudio, el 36.4% necesitaron cirugía. De las mujeres, el 38.90% recibieron tratamiento conservador y el 61.30% se sometieron a cirugía. CONCLUSIONES: Encontramos que el sexo femenino, los vómitos, la guardia, el rebote, los niveles de proteína C reactiva superiores a 75 mg/l, el aumento del diámetro intestinal y una zona de transición en las imágenes de TC indican una fuerte necesidad de cirugía.

Prolonged adhesiolysis to pregnancy interval is associated with placenta accreta spectrum in women with intrauterine adhesion.

BACKGROUND: Both the trauma of endometrium and hysteroscopic adhesiolysis can lead to a high rate of placenta accreta spectrum (PAS) in women with intrauterine adhesion (IUA). This study analysed the impact of time interval from adhesiolysis to pregnancy on PAS in IUA women. METHODS: Patients diagnosed with IUA who underwent adhesiolysis in Anhui Women and Children's Medical Centre between January 2016 and December 2020 were included in this case-series study. Clinical data were obtained from electronic medical records and telephone interviews. RESULTS: Among a total of 102 IUA women with successful pregnancies, 8 (7.8%) suffered from miscarriages with PAS, and 94 (92.2%), 47 with PAS and 47 without PAS, had successful delivery. The total prevalence of PAS in pregnant women with IUA was 53.9% (55/102). The average time from adhesiolysis to pregnancy in the PAS group was significantly longer than in the non-PAS group (14.2 ± 5.7 vs. 10.3 ± 4.4 months, p = 0.000). Regression analysis showed that AFS grade (OR = 7.40, 95% CI 1.38-39.73, p = 0.020) and adhesiolysis to pregnancy interval time between 12 and 24 months (OR = 12.09, 95% CI 3.76-38.83, p = 0.000) were closely related to PAS. A Kaplan-Meier analysis showed the median interval time to PAS was 16.00 months (95% CI 15.11-16.89). CONCLUSIONS: We assume that prolonged adhesiolysis to pregnancy interval may be considered a significant risk factor for PAS in IUA women.

Both the trauma of endometrium and hysteroscopic adhesiolysis can result in a high rate of placenta accreta spectrum in women with intrauterine adhesion. This study analysed the impact of time interval from adhesiolysis to pregnancy on placenta accreta spectrum in intrauterine adhesion women. This case-series study included patients diagnosed with intrauterine adhesion who underwent adhesiolysis in Anhui Women and Children's Medical Centre between January 2016 and December 2020. Clinical data were obtained from electronic medical records and telephone interviews. We assume that prolonged adhesiolysis to pregnancy interval may be considered a significant risk factor for placenta accreta spectrum in intrauterine adhesion women.

Acute Small-bowel Obstruction: An Appraisal of Common Etiology and Management at the Federal Medical Centre, Keffi, North-central Nigeria.

BACKGROUND: Acute small intestinal obstruction is a common surgical emergency in the sub-Saharan region. Over the decades, complicated inguinal hernias have been identified as a leading cause. However, we observed from our clinical practice that complicated inguinal hernias were not the most common etiology. AIMS AND OBJECTIVES: This study aimed to evaluate the common etiology of acute small bowel obstruction in the study center and compare our findings with that from other centers and existing literature. MATERIALS AND METHODS: This was a retrospective, cross sectional study carried out over a period of five years (January 2017 to December 2021). This study looked at the patients presenting with acute, mechanical, small bowel obstruction that did not respond to conservative treatment in our hospital facility. Relevant information were extracted from patients' clinical details and entered into the proforma prepared for this study. RESULTS: A total of 147 patients were recruited into this study out of which 85(57.8%) were males and 62 (42.2%) were females (M:F=1.44:1). Majority (80.3%) of the patients that presented with post-operative bowel adhesion had previous appendectomy. Simple bowel obstruction was seen in 93 (63.3%) patients while strangulated obstruction and gangrenous bowel were seen in 26 (17.7%) patients and 22 (15.0%) patients respectively. Majority (47.6%) of the patients had adhesiolysis done while others had bowel resection. CONCLUSION: The common cause of acute small bowel obstruction as observed in this study is post-operative adhesions arising from previous appendectomy and laparotomies.

Résumé Contexte:Une faible obstruction intestinale a une urgence chirurgicale commune dans la région sub-saharienne. Au cours des décennies, des hernies inguiniques compliquées ont été identifiées comme une cause de premier plan. Cependant, nous avons observé de notre pratique clinique selon laquelle des hernies inguinales compliquées n'étaient pas l'étiologie la plus commune.Objectifs et objectifs:Cette étude visait à évaluer l'étiologie commune de l'obstruction aiguë aux petites interses dans le centre d'études et de comparer nos constatations avec celle d'autres centres et de la littérature existante.Matériaux et méthodes:C'était une étude rétrospective en coupe transversale réalisée sur une période de cinq ans (janvier 2017 à 2021). Cette étude a examiné les patients présentant une obstruction aiguë, mécanique et petite intestinale qui ne répondait pas au traitement conservateur dans notre installation hospitalière. Des informations pertinentes ont été extraites des détails cliniques des patients et ont conclu dans la proforma préparé pour cette étude.Résultats:Un total de 147 patients ont été recrutés dans cette étude dont 85 (57,8%) étaient des hommes et 62 (42,2%) étaient des femelles (M: F = 1.44: 1). La majorité (80,3%) des patients présentés par l'adhésion intestinale post-opératoire avaient une annexe antérieure. Un obstruction d'intestin simples a été observée dans des patients de 93 (63,3%) alors que l'obstruction étrangère et l'intestin gangreneux ont été observés dans des patients de 26 (17,7%) et respectivement respectivement les patients de 22 (15,0%). La majorité (47,6%) des patients avaient une adhésiose faite pendant que d'autres avaient une résection de l'intestin.Conclusion:La cause commune de l'obstruction aiguë aux petites interses comme observé dans cette étude est des adhérences post-opératoires découlant de l'appendecectomie et des laparotomies précédentes.

Abdominal cocoon syndrome (sclerosing encapsulated peritonitis) causing small bowel occlusion in a patient with gastric bypass.

A rare condition, sclerosing encapsulating peritonitis, is characterized by a fibrotic membrane forming over the bowels, leading to intestinal obstruction. In this case of a 56-year-old male patient with a history of laparoscopic gastric bypass, a computed tomography scan showed findings indicative of the condition. Extensive adhesiolysis was performed, and biopsies confirmed the presence of fusiform cells (D2-40 positive on immunochemistry) resembling fibroblasts, within dense collagenous peritoneal tissue sheets, typical of sclerosing encapsulating peritonitis. The prevalence of this condition is uncertain, and diagnosis typically requires a peritoneal biopsy due to the nonspecific clinical presentation.

La peritonitis esclerosante encapsulada es una condición rara caracterizada por una membrana fibrótica que se genera sobre las asas intestinales causando cuadros de oclusión intestinal. Se presenta el caso de un paciente varón de 56 años con antecedente de derivación gastroyeyunal por laparoscopia que presenta oclusión intestinal. Se realizó tomografía computada que evidenció sitio de transición previo al sitio de anastomosis. Se realizó de anastomosis extensa y toma de biopsias. Histológicamente se observó engrosamiento de la membrana peritoneal, células fusiformes (D2-40 positivo en inmunohistoquímica) similares a fibroblastos con láminas de colágeno peritoneal denso. La peritonitis esclerosante encapsulada es una patología de prevalencia desconocida. El cuadro clínico es inespecífico y el diagnóstico definitivo es por patología con biopsia peritoneal.

Nuevo método como preacondicionamiento ante adherenciolisis de difícil manejo / New method as preconditioning for adherenciolysis difficult handling

INTRODUCTION: Intestinal obstruction due to flanges is common in patients with a surgical history. OBJECTIVE: Describe a clinical case with adherenciolysis. Surgery could not be performed, so pneumoperitoneum was used as pre-conditioning for elective surgery. CLINICAL CASE: Patient with intestinal obstruction due to flanges, with impossibility of performing an adherenciolysis, for which catheters are installed to administer progressive pneumoperitoneum in order to optimize the release of flanges in elective surgery, undergoing the postoperative period with enterocutaneous fistula that required multidisciplinary management with percutaneous drainage, parenteral nutrition and nursing care, with a successful result. DISCUSSION: In a flange obstruction, an extensive adherenciolysis is often required, which carries a greater risk of intestinal injury and enterocutaneous fistula. In this case, we believe that it decreased due to the pneumoperitoneum used to generate more lax and manageable flanges. CONCLUSION: Postoperative flanges generate significant morbidity and its surgical management requires an adherenciolysis that may be laborious or impossible in the first instance, requiring in this case the use of progressive pneumoperitoneum for complete flange release, a technique not described in the literature for this purpose.

INTRODUCCIÓN: La obstrucción intestinal por bridas es frecuente en pacientes con antecedentes quirúrgicos. OBJETIVO: Describir un caso clínico con adherenciolisis frustra por cirugía, utilizando neumoperitoneo como preacondicionamiento para cirugía electiva. CASO CLÍNICO: Paciente con obstrucción intestinal por bridas, con imposibilidad de adherenciolisis, por lo que se instalan catéteres para administrar neumoperitoneo progresivo con el fin de optimizar la liberación de bridas en cirugía electiva, cursando en el postoperatorio con fístula enterocutánea que requirió manejo multidisciplinario con drenaje percutáneo, nutrición parenteral y cuidados por enfermería, que finalmente resultó exitoso. DISCUSIÓN: En una obstrucción por bridas muchas veces se requiere una adherenciolisis extensa que conlleva mayor riesgo de lesión intestinal y fístula enterocutánea, que en este caso creemos que disminuyó debido al neumoperitoneo utilizado para generar bridas más laxas y manejables. CONCLUSIÓN: Las bridas postoperatorias generan morbilidad importante y su manejo quirúrgico requiere adherenciolisis que puede resultar laboriosa o imposible en primera instancia, requiriendo en este caso el uso de neumoperitoneo progresivo para la liberación de bridas completa, técnica no descrita en la literatura para este fin.

Etiology and management outcomes of adult mechanical bowel obstruction in Nigeria: A systematic review and meta-analysis.

BACKGROUND: Adult mechanical bowel obstruction (AMBO) has been previously reported to be majorly caused by hernias in developing countries. In Nigeria, however, there has been a recent change in pattern with adhesions now being the leading cause. The aim of this systematic review is to examine the changing pattern of the causes, and outcomes of patients managed for AMBO in Nigeria. METHODS: Relevant keywords relating to AMBO were used to conduct a search on PubMed, Web of Science, Google Scholar, and AJOL. The search returned 507 articles, which were subjected to title, abstract, and full text screenings, according to the inclusion and exclusion criteria. This generated 10 articles which were included in the final qualitative synthesis. RESULTS: The total sample size across the 10 studies was 1033. Adhesions, hernias, and intra-abdominal tumors, responsible for 46.25%, 26.31%, and 12.23% of cases respectively, were the major causes of AMBO in Nigeria. 65.6% of cases were managed operatively and 34.4% were managed conservatively. The meta-analysis revealed high morbidity and mortality rates of 31% (95% CI: 17; 44, 5) and 11% (95% CI: 6; 15, 5), respectively, among adult patients managed for mechanical bowel obstruction in Nigeria. CONCLUSIONS: Adhesion, which results predominantly from appendicectomy is the most common cause of AMBO in Nigeria. This is unlike former reports where hernia was the most common cause. Morbidity results majorly from wound infection, recurrent adhesions, and postoperative enterocutaneous fistula. The mortality rate is similar to reports from various West African studies, and it is significantly influenced by surgical intervention time.

The Risk of Adhesive Bowel Obstruction in Children With Appendicitis: A Systematic Review.

OBJECTIVE: Complicated appendicitis is associated with a higher risk of postoperative complications, including adhesive bowel obstruction. The aim of this meta-analysis is to investigate the difference in rates of postoperative bowel obstruction in paediatric patients with complicated versus simple appendicitis and whether this is influenced by the surgical approach. METHODS: A systematic literature search following PRISMA guidelines was conducted using MEDLINE, Embase and Cochrane Library for studies that analysed incidence of adhesive bowel obstruction in paediatric patients after appendicectomy. Studies from 1998 to 2022 were included in analysis. The study protocol was registered on PROSPERO (ID CRD42022309769). RESULTS: Pooled analysis of 6 studies with low risk of bias and adequate follow up periods, considering 58,962 cases of appendicectomy, revealed complex appendicitis was associated with a near two-fold increase in incidence of SBO (pooled odds ratio 2.02 (95% CI 1.35-2.69)). Interestingly, a similar pooled analysis of 10 studies, considering 62,433 cases of appendicectomy, revealed no significant difference between open and laparoscopic management of complex appendicitis (pooled odds ratio 0.93 (95% CI 0.24 to 1.62)). CONCLUSION: Complex appendicitis is associated with a two-fold increase in the rates of adhesive bowel obstruction. Whilst there are cosmetic advantages of a laparoscopic approach, surgical expertise should be favoured in decision making relating to surgical approach (laparoscopic versus open) as the evidence for a laparoscopic approach reducing risks of adhesive bowel obstruction is not convincing. LEVEL OF EVIDENCE: Level II.

A systematic review of participant descriptors reported in studies of adhesive small bowel obstruction.

AIM: Reporting of participant descriptors in studies of adhesive small bowel obstruction (ASBO) can help identify characteristics associated with favourable outcomes and allow comparison with other studies and real-world clinical populations. The aim was to identify the pattern of participant descriptors reported in studies assessing interventions for ASBO. METHOD: This systematic review was registered with PROSPERO (CRD42021281031) and reported in line with the PRISMA checklist. Systematic searches of Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were undertaken to identify studies assessing operative and non-operative interventions for adults with ASBO. Studies were dual screened for inclusion. Descriptors were categorised into conceptual domains by the research team. RESULTS: Searches identified 2648 studies, of which 73 were included. A total of 156 unique descriptors were identified. On average, studies reported 12 descriptors. The most frequently reported descriptors were sex, age, SBO aetiology, history of abdominal surgery, BMI and ASA classification. The highest number of descriptors in a single study was 34, compared to the lowest number of descriptors which was one. Pathway factors were the least frequently described domain. Overall, 37 descriptors were reported in just one study. CONCLUSION: There is a lack of consistency in participant descriptors reported in studies of SBO. Furthermore, a significant proportion of the descriptors were used infrequently. This makes it challenging to assess whether study participants are representative of the wider population. Further work is required to develop a Core Descriptor Set to standardise the reporting of patient characteristics and reduce heterogeneity between studies.

Type of Prior Operation Does Not Predict Surgical Intervention for Small Bowel Obstruction.

Background: Patients with prior abdominal surgeries are at higher risk for intra-abdominal adhesive tissue formation and subsequently higher risk for small bowel obstruction (SBO).Purpose: In this study, we investigated whether surgical intervention for SBO was more likely following specific types of abdominal surgeries.Research Design: With retrospective chart review, we pooled data from 799 patients, ages 18 to 89, admitted with SBO between 2012 and 2019. Patients were evaluated based on whether they underwent surgery or were managed conservatively. They were further compared with regard to past surgical history by way of type of abdominal surgery (or surgeries) undergone prior to admission.Results: Of the 799 patients admitted for SBO, 206 underwent surgical intervention while 593 were managed nonoperatively. There was no significant difference in number of prior surgeries (2.07 ± 1.56 vs 2.36 ± 2.11, P = .07) or in number of comorbidities (2.39 ± 1.97 vs 2.65 ± 1.93, P = .09) for surgical vs non-surgical intervention. Additionally, of the operations evaluated, no specific type of abdominal surgery predicted need for surgical intervention in the setting of SBO. However, for both surgical and non-surgical intervention following SBO, pelvic surgery was the most common type of prior abdominal surgery (45% vs 43%). There are significantly more female pelvic surgeries in both the operative (91.4% vs 8.6%, P < .0001) and nonoperative groups (89.9% vs 10.2%, P < .0001).Conclusion: Ultimately, no specific type of prior operation predicted the need for surgical intervention in the setting of SBO.

Prevalence of chronic endometritis in infertile women undergoing hysteroscopy and its association with intrauterine abnormalities: A Cross-Sectional study.

OBJECTIVE: Chronic endometritis (CE) is an inflammatory condition with several different risk factors. We aimed to examine whether intrauterine abnormalities, such as endometrial polyps, submucosal myomas, intrauterine adhesions, or a septate uterus, were associated with an increased likelihood of developing chronic endometritis. METHODS: A cross-sectional study was conducted on 335 infertile women who underwent hysteroscopy surgery at the Ayatollah Taleghani Hospital Infertility Center, affiliated by Shahid Beheshti University of Medical Sciences, in 2022. All participants in the study underwent hysteroscopic surgery, which allowed for direct visualization of the intrauterine cavity, and endometrial biopsies were taken for further analysis. To characterize endometritis, plasma cell infiltration was assessed. Patients with ≥5 plasma cells observed in 10 high-power fields were defined as having chronic endometritis. RESULTS: Endometritis was observed in 51.3% of the patients, totaling 172 individuals. Logistic regression analysis revealed that patients with endometrial polyps had 5.2 times higher odds of developing endometritis compared to patients without polyps (95% CI = 2.9, 9.2) (p-value <0.001). Similarly, patients with intrauterine adhesions had a significant increase in the odds of endometritis (OR = 4.6, 95% CI = 2.1, 10.1) (p-value <0.001). CONCLUSIONS: Treatment or removal of endometrial abnormalities through hysteroscopic procedures may help to reduce the risk of chronic endometritis and improve fertility outcomes. Further research is necessary.

Predictive Factors of Intestinal Ischaemia in Adhesive Small Bowel Obstruction.

OBJECTIVE: To identify the predictive factors of intestinal ischaemia in adhesive small bowel obstruction (ASBO) and develop an intestinal ischaemia risk score. STUDY DESIGN: Observational study. Place and Duration of the Study: Department of General Surgery, Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China, from January 2017 to February 2022. METHODOLOGY: ASBO was determined by findings at laparotomy. The assessment of small bowel's viability was conducted through surgical inspection and subsequent histological examination of the surgical specimen. Univariate and multivariate analyses were conducted to ascertain the risk factors associated with intestinal ischaemia. RESULTS: In total, 79 patients were included. Factors entered into multivariate analysis associated with intestinal ischaemia were; rebound tenderness (odds ratio (OR): 7.8, 95% confidence interval (CI):1.7-35.3; p=0.008), procalcitonin (PCT) >0.5 ng/mL (OR: 11.7, 95% CI: 2.3-58.1; p=0.003), and reduced bowel wall enhancement on computerised tomography (CT) scan (OR: 12.2, 95% CI:2.4-61.5; p=0.003). Among patients with 0, 1, 2, and 3 factors, the rate of intestinal ischaemia increased from 0% to 49%, 72%, and 100%, respectively. According to the number of risk factors, the area under the receiver operating characteristic curve for the determination of intestinal ischaemia was 0.848 (95% CI: 0.764-0.932). CONCLUSION: Rebound tenderness, PCT levels >0.5 ng/mL, and reduced bowel wall enhancement are risk factors of intestinal ischemic injury that require surgery within the context of ASBO. These factors need to be closely monitored that could assist clinicians in avoiding unnecessary laparotomies and selecting patients eligible for surgery. KEY WORDS: Intestinal obstruction, Ischaemia, Adhesions.

Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer.

INTRODUCTION: This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC). METHODS: Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups. RESULTS: The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n =68/1544 vs. 9.7%, n =156/1604, P <0.0001). Compared with the TOS group, the MIS group had significantly different ( P <0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to ( P <0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3-12 months) onset (64.7%), while that in the TOS group ( P <0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more ( P <0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8 vs. 14.1%, P =0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group. CONCLUSIONS: The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.

A Comparative Study of Laparoscopic versus Open Management of Index Small Bowel Obstruction in Children.

INTRODUCTION: There is limited literature on the optimal approach to treat adhesive small bowel obstruction (ASBO) in children. We sought to compare rates and outcomes of laparoscopic (LAP) and open (OPEN) surgery for pediatric ASBO. METHODS: A California statewide database was used to identify children (<18 years old) with an index ASBO from 2007 to 2020. The primary outcome was the type of operative management: LAP or OPEN. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications. We excluded patients treated non-operatively. RESULTS: Our study group had 545 patients. 381 (70%) underwent OPEN and 164 (30%) LAP during the index admission. Over the study period, there was increasing use of laparoscopic surgery, with higher use in older children (p < 0.001). LAP was associated with fewer overall complications (65.2% vs. 81.6%, p < 0.001), with a decreasing trend in complications over time (p < 0.001). The LAP group had significantly lower rates of bowel resection (4.9% vs. 17.1%, p < 0.001), length of stay (LOS) (17 vs. 23 days, p < 0.001), and TPN use (12.2% vs. 29.1%, p < 0.001). Mortality rates were equivalent. Although the LAP group had lower readmission rates (22.6% vs. 37.3%, p < 0.001), the length of time between discharge and readmission was similar (171 vs. 165 days, p = 0.190). DISCUSSION: The use of laparoscopic surgery for index ASBO increased over the study period. However, it was less commonly utilized in younger children. LAP had fewer overall complications as well as shorter LOS, decreased TPN use, and fewer readmissions. The benefits and risks of each approach must be weighed. LEVEL OF EVIDENCE: III.

Hysteroscopic Lysis of Complex Uterine Adhesions After Interventional Radiology-Guided Access.

OBJECTIVE: To demonstrate a novel surgical technique using hysteroscopic lysis of adhesions after interventional radiology (IR)-guided access in patients with severe intrauterine adhesions and challenging uterine access. DESIGN: This video illustrates the technique of the safe division of intrauterine adhesions after IR-guided access. SETTING: Conventional hysteroscopic adhesiolysis might be inadequate or risky in cases of severely narrowed or obstructed uterine flow tract, possibly resulting in incomplete adhesiolysis, false passages, or uterine perforation. This video presents 2 cases from a tertiary center involving a multidisciplinary team of a reproductive surgeon and an interventional radiologist. The first case involves a 38-year-old with severe Asherman syndrome, who experienced unsuccessful attempt to treat adhesions that was complicated by a false passage. The second case involves a 39-year-old with recurrent severe Asherman syndrome and a history of unsuccessful attempts at hysterosalpingogram and conventional hysteroscopic lysis of adhesions. INTERVENTIONS: In the IR suite, the patient was put in a lithotomy position on the fluoroscopy table. A vaginal speculum was inserted exposing the cervix. The procedure was performed using intravenous sedation and topical anesthetic spray applied to the cervix. Using fluoroscopy, a balloon cannula was inserted through the cervix, followed by contrast injection to assess uterine access. If there is no route, transvaginal ultrasound-guided needle cannulation of the main portion of the uterine cavity would be performed, approximating as closely as possible to the expected route of the cervical canal. A guidewire followed by a locked loop catheter was advanced through adhesions into the uterine cavity. The catheter was left protruding from the cervix to guide the hysteroscope. The patient was then transferred to the operating room for the hysteroscopic procedure. Under the guidance of the intrauterine catheter, the adhesions were carefully lysed using cold scissors. The endometrial cavity and tubal openings were inspected to ensure complete adhesiolysis and exclusion of any other copathologies. CONCLUSION: IR guidance can provide a safe and effective approach to hysteroscopic lysis of adhesions in patients with challenging intrauterine adhesions and difficult uterine access, such as patients with severe Asherman syndrome, intractable cervical stenosis, uterine wall agglutination, previous adhesiolysis failure, marked fixed retroverted retroflexed uteri, and previous false passage or uterine perforation.

Adhesive small bowel obstruction: predictive factors of laparoscopic failure.

The adoption of laparoscopy for the management of adhesive small bowel obstruction (ASBO) patients is debated. The laparoscopic approach has been associated with a considerable conversion-to-open rate. Nonetheless, reliable predictors of conversion are still unclear. The present study aimed to identify factors associated with conversion to open in ASBO patients who underwent laparoscopic surgery. Patients who underwent laparoscopic surgery for ASBO and were admitted to our unit between December 2014 and October 2022 were retrospectively evaluated. The patients were categorized into two groups: patients who underwent complete laparoscopy approach (Group 1) and patients converted to open technique (Group 2). Demographic, clinical, and radiological features, intraoperative findings, and postoperative outcomes were compared. A total of 168 patients were enrolled: 100 patients (59.5%) were included in Group 1, and 68 patients (40.5%) were included in Group 2. The rate of ischemia (p = 0.023), surgical complications (p = 0.001), operative time (p < 0.0001), days of nasogastric tube maintenance (p < 0.0001), time to canalization (p < 0.0001), and length of hospital stay (p < 0.0001) were significantly higher in Group 2 than Group 1. Following univariate analysis, the presence of feces signs (p = 0.044) and high mean radiodensity of intraperitoneal free fluid (p = 0.031) were significantly associated with Group 2 compared with Group 1. Following multivariate analysis, the feces sign was a significant predictive factor of conversion (OR 1.965 [IC 95%]; p = 0.046). Laparoscopic treatment is a safe and effective approach in patients affected by ASBO. The feces sign may be a predictive factor of conversion and could guide the surgeon in selecting the appropriate management of patients affected by ASBO.

Feasibility of Gastrografin Use for Adhesive Small Bowel Obstruction in Low-Income Countries.

INTRODUCTION: Small bowel obstruction (SBO) is one of the most common causes for hospital admission in Ethiopia. The use of water-soluble contrast agents (WSCAs) such as Gastrografin to manage adhesive SBO can predict nonoperative resolution of SBO and reduce decision time to surgery and length of hospital stay. However, nothing is known about practice patterns and Gastrografin use in low-income settings. We sought to characterize current management practices, including use of WSCAs, as well as outcomes for patients with SBO in Addis Ababa, Ethiopia. METHODS: We conducted a mixed-methods study consisting of a survey of surgeons throughout Ethiopia and a retrospective record review at five public, tertiary care-level teaching hospitals in Addis Ababa. RESULTS: Of the 76 surgeons who completed the survey, 63% had heard of the use of WSCAs for SBO and only 11% used oral agents for its management. Chart review of 149 patients admitted with SBO showed the most common etiology was adhesion (39.6% of admissions), followed by small bowel volvulus (20.8%). Most patients (83.2%) underwent surgery during their admission. The most common diagnosis in patients who did not require surgery was also adhesion (68.0%), as well as for those who had surgery (33.9%), followed by small bowel volvulus (24.2%). CONCLUSIONS: The etiology of SBO in Ethiopia may be changing, with postoperative adhesions becoming more common than other historically more prevalent causes. Although a Gastrografin protocol as a diagnostic and potentially therapeutic aid for SBO is feasible in this population and setting, challenges can be anticipated, and future studies of protocol implementation and effectiveness are needed to further inform its utility in Ethiopia and other low-income and middle-income countries.

Small bowel diaphragm disease with multiple cluster lesions in one segment of the small bowel mimicking an adhesion band: A case report.

RATIONALE: Small bowel diaphragm disease (SBDD) is a rare case, caused by long-term administration of nonsteroidal anti-inflammatory drugs (NSAIDs). The circumferential diaphragm in the lumen of small bowel causing mechanical obstruction is the characteristic finding. PATIENT CONCERNS: A 74-year-old male was transferred to Pusan National University Yangsan Hospital (PNUYH) due to abdominal pain lasting for 2 months. He was treated in the local medical center (LMC) with Levin tube insertion and Nil Per Os (NPO) but showed no improvement. DIAGNOSIS: According to abdomen-pelvis computed tomography (CT) result, small bowel obstruction due to the adhesion band was identified, showing dilatation of the small bowel with abrupt narrowing of the ileum. INTERVENTIONS: Laparoscopic exploration was done but failed to find an adhesion band. An investigation of the whole small bowel was done with mini-laparotomy. At the transitional zone, the intraluminal air could not pass so the segmental resection of small bowel including the transitional zone and end-to-end anastomosis was done. OUTCOMES: After surgery, every laboratory finding recovered to the normal range in 4 days, but the patient's ileus lasted for 8 days. The patient's symptoms were relieved after defecation, he was discharged on postoperative day 10. LESSONS: For patients who show mechanical obstruction without an operation history but with long-term administration of NSAIDs, the clinicians should suspect small bowel diaphragm disease.

Individualization of the best approach for adhesive small bowel obstruction.

BACKGROUND: Laparoscopic postoperatives outcomes in adhesiolysis are promising but conversion and morbidity remains high. The objective of our study was to determine preoperative factors to individualize and select the most appropriate approach for each patient. METHODS: Patients ≥18 years old undergoing emergent surgery for adhesive small bowel obstruction and internal hernias were evaluated. Bivariate and multivariate analysis were performed to investigate factors related to conversion to open surgery and to the type of adhesions. RESULTS: Of 333 patients, 224 were operated by laparotomy and 109 by laparoscopy (conversion rate: 40%). Previous abdominal wall mesh, type of adhesions, bowel lesion, need for intestinal resection and laparoscopic skills were statistically related to conversion. In the multivariate analysis, complex adhesions (OR 4.3, 95% CI 1.5-12.2; P = 0.006), the need for intestinal resection (OR 14.16, 95% CI 2.55-78.68; P = 0.002), and non-advanced laparoscopy surgeons (OR 4.31, 95% CI 1.56-11.94; P = 0.005) were independent factors for conversion to open surgery. ASA III-IV, previous surgeries, previous abdominal mesh and previous adhesiolysis were related to complex adhesions. Previous laparoscopic surgery and internal hernia or closed loop in computed tomography were associated with simple adhesions as a cause of the obstruction. In the multivariate, previous adhesiolysis (OR 4.76, 95% CI 1.23-18.3; P = 0.023) and the findings on computed tomography were significantly related with the type of adhesion. CONCLUSION: Some preoperative factors allow to individualize the surgical approach in the adhesive small bowel obstruction improving surgical outcomes.

A Neglected Extensor Hallucis Longus Tendon Rupture Caused by Arthritic Adhesion.

Extensor hallucis longus tendon injury is relatively rare and is principally caused by a laceration when a sharp object is dropped on the instep. Primary suturing is possible if the injury is acute, but if the tear is chronic, tendon contracture causes the space between the edges of the tear to widen, disrupting the end-to-end connection. In particular, a claw toe or checkrein foot deformity may develop over time due to adhesion of the lower leg tendons near the fracture site or scar. We report on a 44-year-old man who visited our outpatient clinic complaining of pain in the right foot and a hindered ability to extend his great toe. He had enjoyed playing soccer during his schooldays; since that time, the extension of that toe had become somewhat difficult. T2-weighted sagittal magnetic resonance imaging revealed that the continuity of the extensor hallucis longus tendon had been lost at the distal phalangeal base attachment site, and that the region of the proximal tendon was retracted to level of the middle shaft of the proximal phalanx. The findings allowed us to diagnose extensor hallucis longus tendon rupture accompanying osteoarthritic changes in the joint and soft tissues. We performed surgical tenorrhaphy and adhesiolysis. This is a rare case of extensor hallucis longus tendon rupture caused by minor trauma. Arthritis that developed at a young age caused the adhesions. If patients with foot and ankle arthritis show tendon adhesion at the arthritic site, tendon rupture can develop even after minor trauma or intense stretching.