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.

Nutritional Status as a Prognostic Factor for Survival in Palliative Care: A Retrospective Observational Analysis of Home Parenteral Nutrition in Cancer Patients with Inoperable Malignant Bowel Obstruction.

Palliative care patients with malignant bowel obstruction are particularly at risk of developing malnutrition, which in turn directly shortens survival time and worsens quality of life (QoL). According to the available data, the survival time in this patient group is often less than three months. To avoid further complications related to malnutrition and poor outcomes in oncological therapy, nutritional therapy such as home parenteral nutrition (HPN) is offered. The aim of this study was to investigate whether nutritional status is a prognostic factor for survival in palliative care patients with malignant inoperable bowel obstruction qualified for home parenteral nutrition and which nutritional assessment tool has the most accurate prognostic value. This retrospective observational analysis included 200 patients with malignant bowel obstruction referred for home parenteral nutrition between January 2018 and August 2023. The analysis included laboratory test results, body mass index (BMI), Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Geriatric Nutritional Risk Index (GNRI), Prognostic Nutritional Index (PNI) and malnutrition as defined by the Global Leadership Initiative on Malnutrition (GLIM). The average survival time of the patients was 75 days. Patients with higher NRI and PNI scores were more likely to survive (NRI: p < 0.001; PNI: p < 0.001). The GLIM criteria, SGA scores and BMI values did not prove to be good prognostic factors for survival (GLIM p = 0.922, SGA p = 0.083, BMI p = 0.092). The results suggest that the use of NRI and PNI may be helpful in prognosing survival in these patients and that prevention of the development of malnutrition through earlier nutritional assessment and intervention should be considered in this patient group.

Improving outcomes in emergency general surgery: Construct of a collaborative quality initiative.

BACKGROUND: Emergency general surgery conditions are common, costly, and highly morbid. The proportion of excess morbidity due to variation in health systems and processes of care is poorly understood. We constructed a collaborative quality initiative for emergency general surgery to investigate the emergency general surgery care provided and guide process improvements. METHODS: We collected data at 10 hospitals from July 2019 to December 2022. Five cohorts were defined: acute appendicitis, acute gallbladder disease, small bowel obstruction, emergency laparotomy, and overall aggregate. Processes and inpatient outcomes investigated included operative versus nonoperative management, mortality, morbidity (mortality and/or complication), readmissions, and length of stay. Multivariable risk adjustment accounted for variations in demographic, comorbid, anatomic, and disease traits. RESULTS: Of the 19,956 emergency general surgery patients, 56.8% were female and 82.8% were White, and the mean (SD) age was 53.3 (20.8) years. After accounting for patient and disease factors, the adjusted aggregate mortality rate was 3.5% (95% confidence interval [CI], 3.2-3.7), morbidity rate was 27.6% (95% CI, 27.0-28.3), and the readmission rate was 15.1% (95% CI, 14.6-15.6). Operative management varied between hospitals from 70.9% to 96.9% for acute appendicitis and 19.8% to 79.4% for small bowel obstruction. Significant differences in outcomes between hospitals were observed with high- and low-outlier performers identified after risk adjustment in the overall cohort for mortality, morbidity, and readmissions. The use of a Gastrografin challenge in patients with a small bowel obstruction ranged from 10.7% to 61.4% of patients. In patients who underwent initial nonoperative management of acute cholecystitis, 51.5% had a cholecystostomy tube placed. The cholecystostomy tube placement rate ranged from 23.5% to 62.1% across hospitals. CONCLUSION: A multihospital emergency general surgery collaborative reveals high morbidity with substantial variability in processes and outcomes among hospitals. A targeted collaborative quality improvement effort can identify outliers in emergency general surgery care and may provide a mechanism to optimize outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Relief of Obstruction in Left-Sided Obstructive Colon Cancer: Nationwide Analysis of Applied Treatment in the Palliative Setting.

BACKGROUND: For relief of bowel obstruction in left-sided obstructive colon cancer (LSOCC), a self-expandable metal stent (SEMS) or decompressing stoma (DS) can be placed. In a curative setting, these two strategies have been extensively studied as a bridge to elective resection. Guidelines recommend SEMS as the preferred option in the palliative setting, but adherence in daily practice is unknown. Therefore, this study aimed to gain more insight into patients with LSOCC who received palliative treatment with SEMS or DS at a national level. METHODS: A retrospective population-based cohort study was conducted in the Netherlands. Data from the Netherlands Cancer Registry (NCR) on all patients with LSOCC treated with DS or SEMS not followed by resection of the primary tumour between January 1, 2015, and December 31, 2019, were analysed. Type of treatment (DS or SEMS) for different clinical scenarios, was the main outcome of this study, and was also evaluated over the years (2015-2019). RESULTS: Palliative treatment with SEMS or DS for LSOCC was performed in 1077 patients, of whom 79.2% had metastatic disease (M1). Patients without metastatic disease (M0) were older (≥ 80 years M0 67.4%, M1 25.3%, P < 0.001), had a worse clinical condition (ASA III 51.4% versus 36.37%, ASA IV-V 13.3% versus 4.0% P < 0.001) and presented with higher tumour stage (cT4 55.4% versus 33.5%, % P < 0.001). DS was performed in 91.5% of the patients and SEMS in 8.5%. The proportion of DS did not significantly differ between patients with M1 and M0 (91.8% vs. 90.2% respectively, P = 0.525). No increase in SEMS application was observed over the years, with a stable overall proportion of DS of 91-92% per year. In the multivariable analyses, ninety-day mortality and overall survival were not significantly different between SEMS and DS. CONCLUSIONS: This study revealed that DS was the primary treatment modality for palliative management of LSOCC in the Netherlands between 2015 and 2019, while the guidelines recommended SEMS as preferred treatment. For patients with LSOCC eligible for stenting in the palliative setting, SEMS placement should become more available and accessible as the preferred treatment option, to avoid a stoma in the terminal phase of life.

Perforación y obstrucción colónica: conducta de los coloproctólogos latinoamericanos / Perforation and obstruction of the colon: behavior of the latin american colon and rectal surgeons

Resumen Objetivo: Conocer las diferentes conductas que realizan los cirujanos coloproctólogos latinoamericanos en relación con las urgencias colónicas. Materiales y Método: Estudio transversal, utilizando encuesta vía web con preguntas de selección múltiple. La encuesta fue enviada a las distintas Sociedades Coloproctológicas Latinoamericanas, así como a la Asociación Latinoamericana de Coloproctología (ALACP), para su distribución. La encuesta fue escrita en español neutro y traducida al portugués. Se utilizó análisis estadísticos descriptivos y analítico. Resultados: 441 encuestas respondidas completamente de 16 países diferentes. El 85% realiza resección y anastomosis sin ostomía de protección en obstrucciones de colon derecho. En las perforaciones del colon izquierdo, se realiza operación de Hartmann en el 63,3% de los casos que presentan peritonitis purulentas y en el 94,5% de las peritonitis fecaloideas. Discusión: En las obstrucciones colónicas, la resección con anastomosis primaria, es una conducta poco discutida en colon derecho, a diferencia de las obstrucciones del lado izquierdo, en donde realizar una operación de Hartmann es una conducta tan válida como la resección y anastomosis. En los cuadros de perforación, la decisión de resección y anastomosis primaria es multifactorial, tomando relevancia la estabilidad hemodinámica del paciente. En estos últimos casos, realizar una resección con ostomía, es la respuesta de gran parte de los encuestados. Conclusiones: Los resultados de cada situación, en su mayoría, presentan una tendencia clara hacia una conducta en particular; solo en el caso de obstrucción de colon izquierdo, se observan dos conductas (operación de Hartmann o anastomosis primaria) ambas validadas por la literatura internacional.

Objective: Learn about the different management options performed by latin american colon and rectal surgeons, in relation to colonic emergencies. Materials and Method: Cross-sectional study, using web survey with multiple-choice questions. The survey was sent to the different Latin America Coloproctological Societies, as well as to ALACP, for distribution. The survey was written in neutral Spanish and translated into Portuguese. Descriptive and analytical statistical analysis was used. Results: 441 complete surveys, from 16 different countries. 85% perform resection and anastomosis without diverting ostomy in obstructions of the right colon. In perforations of the left colon, Hartmann's procedure is performed in 63.3% of case with purulent peritonitis and in 94.5% of fecaloid peritonitis. Discussion: In colonic obstructions, resection with primary anastomosis, is little discussed behavior in the right colon, unlike obstructions on the left side, where performing a Hartmann operation is a behavior as valid as resection and anastomosis. In colonic perforation, the decision of resection and primary anastomosis is multifactorial, taking into account the hemodynamic stability of the patient. In the latter cases, performing an ostomy is the response of a large part of the surveyed. Conclusions: The results in each situation, for the most part, present a clear tendency towards a particular behavior; only in the case of left colon obstruction, two behaviors (Hartmann procedure or primary anastomosis) are both validated by international literature.

Hypertonic saline and pentoxifylline enhance survival, reducing apoptosis and oxidative stress in a rat model of strangulated closed loop small bowel obstruction

OBJECTIVES: Intestinal obstruction has a high mortality rate when therapeutic treatment is delayed. Resuscitation in intestinal obstruction requires a large volume of fluid, and fluid combinations have been studied. Therefore, we evaluated the effects of hypertonic saline solution (HS) with pentoxifylline (PTX) on apoptosis, oxidative stress and survival rate. METHODS: Wistar rats were subjected to intestinal obstruction and ischemia through a closed loop ligation of the terminal ileum and its vessels. After 24 hours, the necrotic bowel segment was resected, and the animals were randomized into four groups according to the following resuscitation strategies: Ringer's lactate solution (RL) (RL-32 ml/kg); RL+PTX (25 mg/kg); HS+PTX (HS, 7.5%, 4 ml/kg), and no resuscitation (IO-intestinal obstruction and ischemia). Euthanasia was performed 3 hours after resuscitation to obtain kidney and intestine samples. A malondialdehyde (MDA) assay was performed to evaluate oxidative stress, and histochemical analyses (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling [TUNEL], Bcl-2 and Bax) were conducted to evaluate kidney apoptosis. Survival was analyzed with another series of animals that were observed for 15 days. RESULTS: PTX in combination with RL or HS reduced the MDA levels (nmol/mg of protein), as follows: kidney IO=0.42; RL=0.49; RL+PTX=0.31; HS+PTX=0.34 (p<0.05); intestine: IO=0.42; RL=0.48; RL+PTX=0.29; HS+PTX=0.26 (p<0.05). The number of labeled cells for TUNEL and Bax was lower in the HS+PTX group than in the other groups (p<0.05). The Bax/Bcl-2 ratio was lower in the HS+PTX group than in the other groups (p<0.05). The survival rate on the 15th day was higher in the HS+PTX group (77%) than in the RL+PTX group (11%). CONCLUSION: PTX in combination with HS enhanced survival and attenuated oxidative stress and apoptosis. However, when combined with RL, PTX did not reduce apoptosis or mortality.

Bacterial translocation and mortality on rat model of intestinal ischemia and obstruction

Abstract Purpose: To develop an experimental model of intestinal ischemia and obstruction followed by surgical resection of the damaged segment and reestablishment of intestinal transit, looking at bacterial translocation and survival. Methods: After anesthesia, Wistar rats was subject to laparotomy, intestinal ischemia and obstruction through an ileal ligature 1.5cm of ileum cecal valve; and the mesenteric vessels that irrigate upstream of the obstruction site to approximately 7 to 10 cm were ligated. Abdominal wall was closed. Three, six or twenty-four hours after, rats were subject to enterectomy followed by an end to end anastomosis. After 24h, mesenteric lymph nodes, liver, spleen and lung tissues were surgically removed. It was studied survival rate and bacterial translocation. GraphPadPrism statistical program was used. Results: Animals with intestinal ischemia and obstruction for 3 hours survived 24 hours after enterectomy; 6hx24h: survival was 70% at 24 hours; 24hx24h: survival was 70% and 40%, before and after enterectomy, respectively. Culture of tissues showed positivity on the 6hx24h and negativity on the 3hx24h. Conclusion: The model that best approached the clinic was the one of 6x24h of ischemia and intestinal obstruction, in which it was observed bacterial translocation and low mortality rate.

Predictores de mortalidad en la oclusión intestinal mecánica por cáncer de colon / Mortality predictors found in the mechanical bowel obstruction from colon cancer

Introducción: la oclusión intestinal es un padecimiento complejo y de difícil manejo, la etiología neoplásica es la primera causa de mortalidad. Objetivo: identificar los factores predictivos de mortalidad en la oclusión intestinal por cáncer de colon. Métodos: estudio explicativo, analítico, de cohorte realizado en el Hospital Provincial Saturnino Lora Torres de Santiago de Cuba, desde enero de 2010 hasta diciembre de 2015. Se seleccionó una muestra de 78 pacientes. Se utilizó la prueba de comparación de proporciones con un nivel de significación de p≤ 0,05 y la prueba de regresión logística multivariable para la identificación de los factores predictivos de la mortalidad. Resultados: existió predominio de los pacientes masculinos (53,8 por ciento); además de la localización del tumor a nivel del colon izquierdo (71,8 por ciento), sin evidenciarse asociación significativa entre estas variables y la mortalidad. El modelo multivariado de regresión logística, arrojó que la edad mayor a los 61 años, el tiempo de inicio de los síntomas superior a las 48 horas, el estado físico ASA IV y V, los procedimientos resecativos y la presencia de choque séptico; se erigen como factores causales en la explicación de la mortalidad. Se estimó una sensibilidad de 86,2, especificidad de 91,2 y porcentaje global predictivo de 89,7. Conclusiones: fue posible la construcción de un modelo predictivo de mortalidad para la oclusión intestinal por cáncer de colon a través de la identificación de las variables altamente influyentes en la defunción(AU)

Introduction: Bowel obstruction is a complex and difficult to manage disease and its neoplastic etiology is the leading cause of mortality. Objective: To identify predictive mortality factors in the bowel obstruction due to colon cancer. Methods: Cohort, explanatory and analytical study conducted in "Saturnino Lora Torres" provincial hospital of Santiago de Cuba, during the period of January 2010 to December 2015. A sample of 78 patients was selected. The proportion comparison test with a significance level of p ≤ 0.05 and the multivariable logistic regression test to identify mortality predictors were used. Results: Male patients (53.8 percent, and the location of tumor at the left colon (71.8 percent) predominated, with no evidence of significant association between these variables and mortality. Multivariate logistic regression model showed that patients aged more than 61 years, the onset of symptoms after 48 hours, ASA IV and V physical state, resection procedures and the presence of septic shock represent causative factors for mortality. Estimated sensitivity was 86.2, specificity 91.2 and overall predictive percentage 89.7. Conclusions: It was possible to design a predictive mortality model for bowel obstruction caused by the colon cancer through the identification of highly influential variables on death(AU)

Escala predictiva de mortalidad en la oclusión intestinal mecánica / Predictive scale of mortality in the intestinal mechanical occlusion

Introducción: la oclusión intestinal mecánica presenta una elevada frecuencia, y constituye un problema cotidiano para el cirujano. En la actualidad, no existen escalas predictivas de la mortalidad que permitan identificar el mayor riesgo de morir en estos pacientes. Objetivo: diseñar una escala predictiva en pacientes operados por esta enfermedad a través de la construcción y validación de un modelo predictivo de mortalidad. Métodos: estudio explicativo, analítico, de cohorte, realizado en el Servicio de Cirugía General del Hospital Provincial de Santiago de Cuba Saturnino Lora Torres, entre enero de 2007 y diciembre de 2013. La muestra fue de 455 pacientes, divididos en un primer grupo, a partir del cual se confeccionó el modelo y otro, que aportó los nuevos casos para validarlo. Se diseñó la escala predictiva, sobre la base de los resultados obtenidos. Resultados: el modelo de regresión logística estimó que la edad mayor a 60 años, el inicio de los síntomas superior a las 48 horas, el estado físico perianestésico IV y V, la presencia de compromiso vascular, los procedimientos resecativos, el shock y las complicaciones posoperatorias, mostraron relación independiente con la muerte, obteniendo indicadores altamente significativos. Con estas variables fue posible conformar la escala predictiva, estimándose una sensibilidad global de 89,4, especificidad de 98,5, valor predictivo positivo de 63,8 y negativo de 99,7, considerada como excelente. Conclusiones: fue construido y validado un modelo; además, se diseñó una escala predictiva de mortalidad en la población de enfermos portadores de oclusión intestinal mecánica(AU)

Factores predictivos de mortalidad en pacientes con oclusión intestinal mecánica / Mortality predictive factors in patients with mechanical bowel occlusion

Se realizó un estudio longitudinal, prospectivo, de cohorte, de 191 pacientes con oclusión intestinal mecánica, operados en el Servicio de Cirugía del Hospital Provincial Docente Clinicoquirúrgico "Saturnino Lora Torres" de Santiago de Cuba, desde enero de 2011 hasta diciembre de 2013, para identificar los factores predictivos de mortalidad. La muestra fue dividida en 2 cohortes: 165 vivos y 26 fallecidos; asimismo, el análisis de los datos se basó en la construcción de un modelo multivariado (regresión logística multivariable), mediante el cual se precisó que la edad por encima de los 60 años, el inicio de los síntomas después de las 48 horas, el estado físico perianestésico IV y V, el daño vascular, los procedimientos resecativos, el estado de choque y las complicaciones posoperatorias, mostraron relación independiente con la muerte. Se estimó 73,1 y 98,8 % de sensibilidad y especificidad, respectivamente y el porcentaje global predictivo fue excelente (95,3).

A cohort longitudinal, prospective study of 191 patients with mechanical bowel occlusion surgically treated in the Surgery Service of "Saturnino Lora Torres" Provincial Teaching Clinical Surgical Hospital in Santiago de Cuba was carried out from January, 2011 to December, 2013, to identify the mortality predictive factors. The sample was divided into 2 cohorts: 165 alive patients and 26 dead patients; also, the data analysis was based on the design of a multivariate model (multivariable logistical regression), by means of which it was confirmed that the age over 60 years, the beginning of the symptoms after 48 hours, the physical perianesthesic condition IV and V, the vascular damage, the resecting procedures, the shock and the postoperative complications, showed independent relation to death. Sensibility, 73.1 and specificity, 98.8% were considered and the global predictive percentage was excellent (95.3).

Resolución endoscópica de la obstrucción de colon mediante el uso de prótesis metálicas autoexpandibles / Endoscopic treatment of colonic obstruction by self-expandable metallic stent placement

Introducción: la obstrucción aguda colónica es una situación que requiere un tratamiento urgente y tiene elevada morbi-mortalidad. Las prótesis metálicas autoexpandibles, lograron un lugar en el armamento terapéutico. Se pueden colocar en forma "definitiva" o como "puente a la cirugía electiva". Las ventajas son reducción de la morbi-mortalidad, evitan cirugías de urgencia no apropiadas. Objetivo: Evaluar la factibilidad del uso de las prótesis, en obstrucción colorrectal, revisión de aspectos técnicos, tasas de éxito y complicaciones. Material y Métodos: Se analizaron todos los pacientes con obstrucción colorrectal ingresados en el Servicio de Coloproctología del Hospital Británico entre Junio 2007 y Junio del 2009, los datos fueron vertidos en una base Excel 2007. Se realizó un análisis, retrospectivo, observacional descriptivo y longitudinal. Las variables analizadas fueron: diagnóstico primario, localización de la obstrucción, intención de colocación de la prótesis, evaluación del éxito terapéutico, y complicaciones del procedimiento. Resultados: Sobre 13 pacientes con obstrucción colorrectal, en 11 (84,6 por ciento) se colocaron 15 PMA, con resolución del cuadro agudo. La edad media fue de 66 años. El 61 por ciento (8 pacientes) fueron de sexo masculino. El éxito técnico fue de 84,6 por ciento (11 pacientes), en 3 como "puente" a cirugía electiva y en 8 en foma definitiva. El éxito terapéutico fue del 100 por ciento. Las complicaciones fueron suboclusión en 1 paciente y migración en 2 pacientes con patología benigna. Conclusión: la colocación de las PMA, son eficaces y seguras con resultados preliminares que refuerzan las ventajas de los procedimientos mini-invasivos.

Background: Acute colonic obstruction is a situation that requires urgent treatment and has high morbidity and mortality. The self-expandable metallic stents achieved a place in the therapeutic armamentarium. May be placed in a “palliative” or “bridge to elective surgery”. The advantages are reducing morbility and mortality, prevent inappropriate emergency surgeries. Objective: To evaluate the feasibility of using prosthetics in colorectal obstruction, review of technical aspects, success rates and complications. Method: we analyzed all patients with colorectal obstruction admitted to the Colorectal Service at the British Hospital between June 2007 and June 2009, data were analyzed in a database Excel 2007. An analysis, retrospective, observational, descriptive was performed and the variables analyzed were: primary diagnosis, location of obstruction, self-expandable metallic stent, assessment of therapeutic success and complications of the procedure. Results: About 13 patients with colorectal obstruction in 11 (84.6 per cent) were placed 15 self-expandable metallic stents, with resolution of acute disease. The mean age was 66 years. 61 per cent (8 patients) were male. Technical success was 84.6 per cent (11 patients) in 3 as a "bridge" to elective surgery and 8 eight in final forms or palliative. Treatment success was 100 per cent. Complications were partial occlusion in 1 patient and migration in two patients with benign disease. Conclusion: The placement of the self-expandable metallic stents, are effective and safe with preliminary results that reinforce the advantages of mini-invasive procedures.

Causas y mortalidad de la obstrucción intestinal en el anciano / Causes and mortality of intestinal obstruction in the elderly patiente

Objetivo: determinar la etiología, sintomatología, y evolución de los pacientes ancianos operados por obstrucción intestinal (OI). Antecedentes: la OI es una de las principales causas de cirugía por urgencia de ancianos, con mortalidad de 20 a 40 por ciento. Se cree que la etiología de estas obstrucciones se debe a defectos de pared, adherencias o problemas oncológicos. Método: se recabaron los datos de sintomatología y hallazgos quirúrgicos en pacientes mayores de 65 años de edad, atendidos por el Servicio de Cirugía General por urgencias, entre diciembre de 1996 a junio de 1998. Resultados: en 104 pacientes ancianos operados por urgencia, 40 fueron por OI, la primera causa fue hernia inguinal y umbilical complicada (35 por ciento). La mortalidad fue de 37 por ciento secundaria a desequilibrio metabólico y neumonías. Conclusiones: las principales causas de OI fueron los defectos de pared abdominal. Recomendamos una inmediata cirugía y corrección preoperatoria de las enfermedades agregadas.

Obstrucción intestinal en el paciente con cáncer: primera parte / Intestinal obstruction in the cancer patient: part one

Objetivos: describir la incidencia, los factores de riesgo, el pronostico, los hallazgos operatorios, la recurrencia y la supervivencia de los pacientes con obstruccion intestinal (0I) y los antecedentes de neoplasia de cualquier origen. Diseño: estudio longitudinal, descriptivo prospectivo. Lugar: hospital de tercer nivel, centro de referencia para el cancer. Pacientes: 88 pacientes con antecedente de neoplasia, con 127 episodios de 0I documentados por clinica y/o paraclínica, hospitalizados entre el 1§. de marzo de 1997 y el 28 de febrero de 1998 (1 año). Resultados: se evaluaron 88 pacientes, 35 hombres (40 por ciento) y 53 mujeres, con diagnostico de 0I. La edad promedio fue 52 años. La neoplasia asociada más frecuente fue el cancer colorrectal (38 por ciento); luego el de cervix (22 por ciento) y estomago (16 por ciento). Al ingreso los estados avanzados y metastásicos constituian en el 67 por ciento (estados 3 y 4), lo que cursa con un riesgo 6 veces mayor de que el origen de la 0I sea maligna (RR=6,1; IC=1,8 a 20,9). En 67 pacientes (76 por ciento) habia antecedente de cirugia, y en 53 (79 por ciento) esta fue por neoplasia. La escala de actividad mostro un estado avanzado (3 a 4) en el 66 por ciento de los casos, siendo uno de los factores determinantes de la posibilidad de cirugia (p<0,0001). Se practico cirugia en 60 pacientes (68 por ciento) y se encontro que en 80 por ciento la causa era maligna, destacando la presencia de carcinomatosis en el 47 por ciento. Hubo morbilidad posoperatoria en 21 pacientes (35 por ciento) y mortalidad posoperatoria en el 18,3 por ciento (11 pacientes). Durante el seguimiento se detectaron 39 episodios de recurrencia de 0I, lo que muestra un mayor numero de recurrencias por parte de los pacientes con tratamiento medico sobre los operados (Kruskal-Wallis=4,7; p=0,03...

Oclusión intestinal: nuestra experiencia en el tratamiento quirúrgico / Bowel obstruction: authors' experience with the surgical management

El síndrome de Oclusión Intestinal representa entre un 20 % y 30 % de los cuadros de Abdomen Agudo. El objetivo es relacinar edad, sexo, riesgo ASA, altura de la oclusión, retardo en el tratamiento quirúrgico con mortalidad, complicaciones médicas y quirúrgicas. Se realizú en el Servicio de Guardia Central H:N:C. UNC.. Diseño: estudio prospectivo y protocolizado. Material y métodos: entre enero de 2004 y enero de 2007, se operaron 52 pacientes con un cuadro de oclusión intestinal. Del total 32 de ellos fueron hombres y 20 mujeres; el promedio de edad correspondió a 52,11 años. Riesgo Quirúrgico: el 46,15 % de los pacientes presentó riesgo A.S.A. III, 38,69 % riesgo A.S.A. II, 11,53 % riesgo A.S.A. I y 9,61 % riesgo A.S.A. IV. Los síntomas mós frecuentes fueron dolor abdominal y distensión abdominal y los signos de distensión abdominal y timpanismo abdominal. Resultados: en las Oclusiones altas las Bridas fueron la causa más frecuente y en Oclusiones bajas el Cáncer de sigmoides. La mortalidad global fue de 13,45 %. Respecto de las Complicaciones médicas postquirúrgicas, 14 pacientes en total las presentron, la más frecuente fue la Insuficiencia Renal Aguda con 9 casos. respecto de las complicaciones del acto quirúrgico, 12 pacientes en toal las presentron; las más frecuentes fueron las infecciones de la herida quirúrgica con 7 casos. Conclusiones: el riesgo A.S.A. elevado mostró ser uno de los factores predictivos más importantes respecto del incremento de la mortalidad en cuadros oclusivos de urgencia, junto con la edad y el retraso de la indicación quirúrgica.

Bowel obstruction syndrome represents 20 to 30 % of acute abdominal consult. Objectives: to relate age, gender, ASA risk, large or smal intestinal obstruction, opportunity chirurgic treatment, medical and clinic complications. Establishment: Central Guard Service of N.C.H. of the C.N.U. Design: protocolized and prospective study. Methods and materials: between January 2004 and January 2007 it has been operated 52 patients with acute bowel obstruction, 32 of them were males and 20 females. The middle age eas 52,11 years. Chirurgic risk: 46,15 % had ASA risk III, 38,69 % had ASA risk II, 11,53 % had ASA risk I, and 9,61 % had ASA risk IV. Most common sympotom was abdominal pain and abdominal distension, and the most common signs were distension and tympanic abdominal. Results: the most common cause of small bowel obstruction sigmoid cancer. Global mortality was 13,45 %. Post chirurgic complications: 9 patients had acute renal failure and 7 had wound surgery infection. Conclusions: the most important factors that increase mortality on acute bwel obstructions are elevated risk ASA, age adn retard of surgery treatment.

Obstrução intestinal: causas e condutas / Intestinal obstruction: causes and conducts

Estudo retrospectivo, realizado no Hospital Governador João Alves Filho, no período de janeiro de 1990 a fevereiro de 1999, tem como objetivo avaliar as principais causas de obstrução intestinal de pacientes que foram admitidos no serviço de urgência, correlacionando-as com as condutas cirúrgicas tomadas. Foram analisados 118 pacientes que deram entrada no serviço de urgência, avaliando idade, sexo, quadro clínico, achado cirúrgico, terapêutica instituída e a morbi-mortalidade. Nos 118 pacientes estudados houve predominância do sexo masculino (59por cento). A faixa etária variou de acordo com as patologias. A principal causa foi brida de delgado (44por cento), seguida por volvo (23por cento), principalmente o de sigmóide (89por cento), e bolo de áscaris (11por cento). Nos pacientes do sexo masculino predominaram as obstruções por invaginação, hérnia e bolo de áscaris. No feminino destacaram-se os tumores, com localização mais comum no sigmóide. Bolo de áscaris e invaginação predominaram nos pacientes com menos de 10 anos, hérnias e bridas entre os 30 e 40 anos, enquanto que tumores e volvo predominaram em pacientes com mais de 50 anos. A terapêutica instituída variou com a patologia e sua apresentação, se simples ou complicada. A morbidade foi de 38por cento, sendo mais comuns os distúrbios hidro-eletrolíticos (18por cento). As patologias que mais apresentaram complicações foram o bolo de áscaris (61por cento) e os tumores (58por cento). A mortalidade foi de 20por cento, ocorrendo mais nos pacientes com tumores (42por cento) e bolo de áscaris (39por cento). As condutas cirúrgicas foram determinadas pelas etiologias, reservando-se os maiores índices de morbi-mortalidade às patologias que acometeram os extremos de idade.

Obstrução intestinal: análise retrospectiva da etiologia e morbi-mortalidade no Hospital de Urgências de Goiânia (HUGO) / Bowel obstruction: retrospective analysis of the etiology and morbi-mortality in the Hospital of Urgencies of Goiânia (HUGO)

A oclusão intestinal ainda desafia os cirurgiões nos tempos atuais, não apenas pela difícil determinação do momento ideal para intervenção cirúrgica, como também pelas dificuldades encontradas na realização do ato operatório em si. Vários autores referem aumento da sua incidência, principalmente às custas de aderências pós-operatórias. O objetivo deste estudo foi o de avaliar uma amostragem regional de pacientes atendidos em serviço de urgência com diagnóstico de obstrução intestinal, comparando os dados com os da literatura disponível. No período compreendido entre janeiro de 1999 e janeiro de 2000, foram revistos os prontuários de pacientes admitidos no Hospital de Urgências de Goiânia (HUGO) com o diagóstico de obstrução intestinal. De um total de 142 pacientes, predominaram as obstruções "baixas"(78 casos) em relação às "altas"(64 casos), o que diferiu da literatura revisada. Aderências foram a causa mais comum de obstrução- 53 casos ou 37,32por cento, seguida por colopatia chagásica- 46 casos ou 32,30por cento (fecaloma 18,3por cento e volvo 14,08por cento), neoplasias colorretais- 22(15,49por cento), hérnias-7(4,92por cento) e outras causas 9,88por cento. Obstrução do intestino grosso foi causada mais comumente por complicações do megacólon chagásico em 58.97por cento das vezes, determinando em 65por cento dos casos o tratamento cirúrgico e em 35por cento o clínico, morbidade geral de 34,55por cento (n=27) e mortalidade de 15,38por cento (n=12).Obstrução de intestino delgado (n=64) foi causada por aderências pós-operatórias em 53 casos(82,8por cento).Destes, necessitaram de cirurgia 62,66por cento (n=33) e tratamento clínico 37,73por cento (n=20) com 30,30por cento(n=19) de enterectomias e 9,09por cento (3) de enterotomias inadvertidas. Ocorreram 8 óbitos (7 casos operados e 1 caso tratado clinicamente). Concluímos que, em nosso meio, a doença aderencial é a causa mais importante de oclusão intestinal e está associada a morbi-mortalidade elevada, quando os casos são tratados em situações de urgência. Destacamos a presença das oclusões, por complicações do megacólon chagásico, como a segunda principal causa de internação e tratamento cirúrgico, o que não é referido na casuística de outros autores. Medidas profiláticas são justificadas nas duas situações.

Obstrucción intestinal en el recién nacido / Congenital intestinal obstruction in the newborn

Se presentan 165 casos de obstrucción intestinal congénita operados dentro de los primeros 28 días de vida en el Departamento de Cirugía Pediátrica del Hospital "San Bartolomé", desde enero de 1982 hasta diciembre de 1991 (10 años). Evaluamos la incidencia, anomalías asociadas, procedimientos quirúrgicos y mortalidad de todas las obstrucciones intestinales congénitas operadas, comparándolas con otras series. La patología más frecuente fue la atresia y estenosis intestinales (83.63 por ciento); predominando las ileales (42 por ciento), seguidas por las ubicadas a nivel yeyunal (29.7 por ciento) y duodenal (27.5 por ciento) y por último, muy alejada, la de colon (0.72 por ciento). La mortalidad la expresamos de manera global, sin discriminar a los recien nacidos por anomalías asociadas, condiciones al momento del nacimiento (edad gestacional y peso) y complicaciones pre y postoperatorias.

Diagnostico y tratamiento de la obstruccion intestinal mecanica / Diagnosis and treatment of mechanical bowel obstruction

Se revisaron las historias clinicas de 166 pacientes que ingresaron al Hospital Universitario del Valle con diagnostico de obstruccion intestinal mecanica durante el ano de 1983. Del total de pacientes, 64% fueron hombres y solo consultaron 39% en un periodo menor de 24 horas entre la iniciacion de los sintomas y la consulta. Los sintomas y signos mas frecuentes fueron: dolor abdominal, 86%; nausea y vomito, 79%; y distension abdominal, 69%. La serie simple de abdomen revelo signos de obstruccion intestinal en 47% pero hay que tener en cuenta que 40% de los pacientes tenian hernias externas encarceladas y a la mayoria no se les solicito el examen. La etiologia de la obstruccion fue: hernias externas, 40.4%; bridas postquirurgicas, 25.9%; lesiones congenitas, 14.5%, invaginacion intestinal, 6.6%; lesiones malignas, 3.6%; y otras causas, 9%. Se encontro el intestino normal en 44.6% de los casos, sufrimiento intestinal en 40.4% y necrosis intestinal en 15%. la mayoria de las obstrucciones estuvieron localizadas a nivel del ileon. La frecuencia global de complicaciones fue de 21.6% y la mortalidad de 2.4%. El promedio de estancia operatoria fue de 6.3 dias