Variation in the management of adhesive small bowel obstruction in the Netherlands: a prospective cross-sectional study.

BACKGROUND: ASBO is a frequent abdominal surgical emergency and a leading cause of morbidity and mortality in emergency surgery. The aim of this study is to provide insight into the current management of adhesive small bowel obstruction (ASBO) and associated outcomes. METHODS AND MATERIALS: A nationwide prospective cross-sectional cohort study was conducted. All patients with clinical signs of ASBO admitted to participating Dutch hospitals were included during a 6 months inclusion period between April 2019 and December 2020. Ninety-day clinical outcomes were described and compared for nonoperative management (NOM) and laparoscopic and open surgery. RESULTS: In 34 participating hospitals, 510 patients were included, of whom 382 (74.9%) had a definitive diagnosis of ASBO. Initial management consisted of emergency surgery in 71 (18.6%) patients and NOM in 311 (81.4%) patients, 119 (31.1%) of whom required delayed surgery after failure of NOM. Surgical interventions started laparoscopically in 51.1%, of which 36.1% were converted to laparotomy. Intentional laparoscopy resulted in shorter hospital stays compared with open surgery (median 8.0 vs. 11.0 days; P <0.001) and comparable hospital mortality (5.2 vs. 4.3%; P =1.000). Oral water-soluble contrast use was associated with a decreased length of stay ( P =0.0001). Hospital stay for surgical patients was shorter in patients who were operated on within 72 h of admission ( P <0.001). CONCLUSION: This nationwide cross-sectional study demonstrates shorter hospital stay in ASBO patients who received water-soluble contrast, were operated within 72 h of admission or were operated with minimally invasive techniques. Results may support the standardization of ASBO treatment.

Predicting long-term risk of reoperations following abdominal and pelvic surgery: a nationwide retrospective cohort study.

BACKGROUND: The risk of reoperations after abdominal and pelvic surgery is multifactorial and difficult to predict. The risk of reoperation is frequently underestimated by surgeons as most reoperations are not related to the initial procedure and diagnosis. During reoperation, adhesiolysis is often required, and patients have an increased risk of complications. Therefore, the aim of this study was to provide an evidence-based prediction model based on the risk of reoperation. MATERIALS AND METHODS: A nationwide cohort study was conducted including all patients undergoing an initial abdominal or pelvic operation between 1 June 2009 and 30 June 2011 in Scotland. Nomograms based on multivariable prediction models were constructed for the 2-year and 5-year overall risk of reoperation and risk of reoperation in the same surgical area. Internal cross-validation was applied to evaluate reliability. RESULTS: Of the 72 270 patients with an initial abdominal or pelvic surgery, 10 467 (14.5%) underwent reoperation within 5 years postoperatively. Mesh placement, colorectal surgery, diagnosis of inflammatory bowel disease, previous radiotherapy, younger age, open surgical approach, malignancy, and female sex increased the risk of reoperation in all the prediction models. Intra-abdominal infection was also a risk factor for the risk of reoperation overall. The accuracy of the prediction model of risk of reoperation overall and risk for the same area was good for both parameters ( c -statistic=0.72 and 0.72). CONCLUSIONS: Risk factors for abdominal reoperation were identified and prediction models displayed as nomograms were constructed to predict the risk of reoperation in the individual patient. The prediction models were robust in internal cross-validation.

Interprofessional simulation of acute care for nursing and medical students: interprofessional competencies and transfer to the workplace.

BACKGROUND: Teamwork and communication are essential tools for doctors, nurses and other team members in the management of critically ill patients. Early interprofessional education during study, using acute care simulation, may improve teamwork and communication between interprofessional team members on the long run. METHODS: A comparative sequential quantitative-qualitative study was used to understand interprofessional learning outcomes in nursing and medical students after simulation of acute care. Students were assigned to a uni- or interprofessional training. Questionnaires were used to measure short and long term differences in interprofessional collaboration and communication between the intervention and control group for nursing and medical students respectively. Semi-structured focus groups were conducted to gain a better understanding of IPE in acute simulation. RESULTS: One hundred and ninety-one students participated in this study (131 medical, 60 nursing students). No differences were found between the intervention and control group in overall ICCAS scores for both medical and nursing students (p = 0.181 and p = 0.441). There were no differences in ICS scores between the intervention and control group. Focus groups revealed growing competence in interprofessional communication and collaboration for both medical and nursing students. CONCLUSIONS: Interprofessional simulation training did show measurable growth of interprofessional competencies, but so did uniprofessional training. Both medical and nursing students reported increased awareness of perspective and expertise of own and other profession. Furthermore, they reported growing competence in interprofessional communication and collaboration in transfer to their workplace.

Risk Factors for Adhesion-Related Readmission and Abdominal Reoperation after Gynecological Surgery: A Nationwide Cohort Study.

More than half of women in developed countries undergo surgery during their lifetime, putting them at risk of adhesion-related complications. Adhesion-related complications include small bowel obstruction, chronic (pelvic) pain, subfertility, and complications associated with adhesiolysis during reoperation. The aim of this study is to predict the risk for adhesion-related readmission and reoperation after gynecological surgery. A Scottish nationwide retrospective cohort study was conducted including all women undergoing a gynecological procedure as their initial abdominal or pelvic operation between 1 June 2009 and 30 June 2011, with a five-year follow-up. Prediction models for two- and five-year risk of adhesion-related readmission and reoperation were constructed and visualized using nomograms. To evaluate the reliability of the created prediction model, internal cross-validation was performed using bootstrap methods. During the study period, 18,452 women were operated on, and 2719 (14.7%) of them were readmitted for reasons possibly related to adhesions. A total of 2679 (14.5%) women underwent reoperation. Risk factors for adhesion-related readmission were younger age, malignancy as indication, intra-abdominal infection, previous radiotherapy, application of a mesh, and concomitant inflammatory bowel disease. Transvaginal surgery was associated with a lower risk of adhesion-related complications as compared to laparoscopic or open surgeries. The prediction model for both readmissions and reoperations had moderate predictive reliability (c-statistics 0.711 and 0.651). This study identified risk factors for adhesion-related morbidity. The constructed prediction models can guide the targeted use of adhesion prevention methods and preoperative patient information in decision-making.

Adhesion-related readmissions after open and laparoscopic colorectal surgery in 16 524 patients.

AIM: Colorectal surgery is associated with a high risk of adhesion formation and subsequent complications. Laparoscopic colorectal surgery reduces adhesion formation by 50%; however, the effect on adhesion-related complications is still unknown. This study aims to compare differences in incidence rates of adhesion-related readmissions after laparoscopic and open colorectal surgery. METHOD: Population data from the Scottish National Health Service were used to identify patients who underwent colorectal surgery between June 2009 and June 2011. Readmissions were registered until December 2017 and categorized as being either directly or possibly related to adhesions, or as reoperations potentially complicated by adhesions. The primary outcome measure was the difference in incidence of directly adhesion-related readmissions between the open and laparoscopic cohort. RESULTS: Colorectal surgery was performed in 16 524 patients; 4455 (27%) underwent laparoscopic surgery. Patients undergoing laparoscopic surgery were readmitted less frequently for directly adhesion-related complications, 2.4% (95% CI 2.0%-2.8%) versus 7.5% (95% CI 7.1%-7.9%) in the open cohort. Readmissions for possibly adhesion-related complications were less frequent in the laparoscopic cohort, 16.8% (95% CI 15.6%-18.0%) versus 21.7% (95% CI 20.9%-22.5%), as well as reoperations potentially complicated by adhesions, 9.7% (95% CI 8.9%-10.5%) versus 16.9% (95% CI 16.3%-17.5%). CONCLUSION: Overall, any adhesion-related readmissions occurred in over one in three patients after open colorectal surgery and one in four after laparoscopic colorectal surgery. Compared with open surgery, incidence rates of adhesion-related complications decrease but remain substantial after laparoscopic surgery.

[A rare cause of hoarseness]. / Een zeldzame oorzaak van heesheid.

BACKGROUND: Hoarseness caused by Ortner's syndrome is a rare diagnosis, first described in 1897 in a patient with an enlarged left atrium due to mitral valve stenosis. Due to mechanical compression on the left recurrent laryngeal nerve patients present with hoarseness. CASE DESCIPTION: A 70 year old male presents with hoarseness and an inability to swallow. Examination reveals a paresis of the left vocal cord. A Computed Tomography scan shows a saccular aneurysm of the proximal descending thoracic aorta, consistent with Ortner's syndrome. Patient was successfully treated with a thoracic endovascular aortic repair procedure. CONCLUSION: Hoarseness is rarely caused by cardiovascular conditions, a more common condition is a lung neoplasm. Thoracic aneurysms as a cause of Ortner's syndrome are often described in combination with a dissection of the aneurysm. Diagnostic work-up of persisting hoarseness without laryngeal pathology should include a contrast enhanced computed tomography (CT) scan to rule our life-threatening conditions.

Laparoscopic versus open approach for adhesive small bowel obstruction, a systematic review and meta-analysis of short term outcomes.

BACKGROUND: Adhesive small bowel obstruction (ASBO) is one of the most frequent causes of emergency hospital admissions and surgical treatment. Current surgical treatment of ASBO consists of open adhesiolysis. With laparoscopic procedures rising, the question arises if laparoscopy for ASBO is safe and results in better patient outcomes. Although adhesiolysis was among the first surgical procedures to be approached laparoscopically, uncertainty remains about its potential advantages over open surgery. Therefore, we performed a systematic review and meta-analysis on the benefits and harms of laparoscopic surgery for ASBO. METHODS: A systematic literature review was conducted for articles published up to May 2019. Two reviewers screened all articles and did the quality assessment. Consecutively a meta-analysis was performed. To reduce selection bias, only matched studies were used in our primary analyses. All other studies were used in a sensitivity analyses. All the outcomes were measured within the 30th postoperative day. Core outcome parameters were postoperative mortality, iatrogenic bowel perforations, length of postoperative stay [days], severe postoperative complications, and early readmissions. Secondary outcomes were operative time [min], missed iatrogenic bowel perforations, time to flatus [days], and early unplanned reoperations. RESULTS: In our meta-analysis, 14 studies (participants = 37.007) were included: 1 randomized controlled trial, 2 matched studies, and 11 unmatched studies. Results of our primary analyses show no significant differences in core outcome parameters (postoperative mortality, iatrogenic bowel perforations, length of postoperative stay, severe postoperative complications, early readmissions). In sensitivity analyses, laparoscopic surgery favored open adhesiolysis in postoperative mortality (relative risk [RR], 0.36; 95% CI, 0.29-0.45), length of postoperative hospital stay (mean difference [MD], -4.19; 95% CI, -4.43 to -3.95), operative time (MD, -18.19; 95% CI, -20.98 to -15.40), time to flatus (MD, -0.98; 95% CI, -1.28 to -0.68), severe postoperative complications (RR, 0.51; 95% CI, 0.46-0.56) and early unplanned reoperations (RR, 0.82; 95% CI, 0.70-0.96). CONCLUSION: Results of this systematic review indicate that laparoscopic surgery for ASBO is safe and feasible. Laparoscopic surgery is not associated with better or worse postoperative outcomes compared with open adhesiolysis. Future research should focus on the correct selection of those patients who are suitable for laparoscopic approach and may benefit from this approach. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis, Level III.

Adhesion-related readmissions after open and laparoscopic surgery: a retrospective cohort study (SCAR update).

BACKGROUND: Adhesions are the most common driver of long-term morbidity after abdominal surgery. Although laparoscopy can reduce adhesion formation, the effect of minimally invasive surgery on long-term adhesion-related morbidity remains unknown. We aimed to assess the impact of laparoscopy on adhesion-related readmissions in a population-based cohort. METHODS: We did a retrospective cohort study of patients of any age who had abdominal or pelvic surgery done using laparoscopic or open approaches between June 1, 2009, and June 30, 2011, using validated population data from the Scottish National Health Service. All patients who had surgery were followed up until Dec 31, 2017. The primary outcome measure was the incidence of hospital readmissions directly related to adhesions in the laparoscopic and open surgery cohorts at 5 years. Readmissions were categorised as directly related to adhesions, possibly related to adhesions, and readmissions for an operation that was potentially complicated by adhesions. We did subgroup analyses of readmissions by anatomical site of surgery and used Kaplan-Meier analyses to assess differences in survival across subgroups. We used multivariable Cox-regression analysis to determine whether surgical approach was an independent and significant risk factor for adhesion-related readmissions. FINDINGS: Between June 1, 2009, and June 30, 2011, 72 270 patients had an index abdominal or pelvic surgery, of whom 21 519 (29·8%) had laparoscopic index surgery and 50 751 (70·2%) had open surgery. Of the 72 270 patients who had surgery, 2527 patients (3·5%) were readmitted within 5 years of surgery for disorders directly related to adhesions, 12 687 (17·6%) for disorders possibly related to adhesions, and 9436 (13·1%) for operations potentially complicated by adhesions. Of the 21 519 patients who had laparoscopic surgery, 359 (1·7% [95% CI 1·5-1·9]) were readmitted for disorders directly related to adhesions compared with 2168 (4·3% [4·1-4·5]) of 50 751 patients in the open surgery cohort (p<0·0001). 3443 (16·0% [15·6-16·4]) of 21 519 patients in the laparoscopic surgery cohort were readmitted for disorders possibly related to adhesions compared with 9244 (18·2% [17·8-18·6]) of 50 751 patients in the open surgery cohort (p<0·005). In multivariate analyses, laparoscopy reduced the risk of directly related readmissions by 32% (hazard ratio [HR] 0·68, 95% CI 0·60-0·77), and of possibly related readmissions by 11% (HR 0·89, 0·85-0·94) compared with open surgery. Procedure type, malignancy, sex, and age were also independently associated with risk of adhesion-related readmissions. INTERPRETATION: Laparoscopic surgery reduces the incidence of adhesion-related readmissions. However, the overall burden of readmissions associated with adhesions remains high. With further increases in the use of laparoscopic surgery expected in the future, the effect at the population level might become larger. Further steps remain necessary to reduce the incidence of adhesion-related postsurgical complications. FUNDING: Dutch Adhesion Group and Nordic Pharma.

Cost-effectiveness of the prevention of adhesions and adhesive small bowel obstruction after colorectal surgery with adhesion barriers: a modelling study.

Background: Adhesion barriers have proven to reduce adhesion-related complications in colorectal surgery. However, barriers are seldom applied. The aim of this study was to determine the cost-effectiveness of adhesion barriers in colorectal surgery. Methods: A decision-tree model was developed to compare cost-effectiveness of no adhesion barrier with the use of an adhesion barrier in open and laparoscopic surgery. Outcomes were incidence of clinical consequences of adhesions, direct healthcare costs, and incremental cost-effectiveness ratio per adhesion prevented. Deterministic and probabilistic sensitivity analyses were performed. Results: Adhesion barriers reduce adhesion incidence and incidence of adhesive small bowel obstruction in open and laparoscopic surgery. Adhesion barriers in open surgery reduce costs compared to no adhesion barrier ($4376 versus $4482). Using an adhesion barrier in laparoscopic procedures increases costs by $162 ($4482 versus $4320). The ICER in the laparoscopic cohort was $123. Probabilistic sensitivity analysis showed 66% and 41% probabilities of an adhesion barrier reducing costs for open and laparoscopic colorectal surgery, respectively. Conclusion: The use of adhesion barriers in open colorectal surgery is cost-effective in preventing adhesion-related problems. In laparoscopic colorectal surgery, an adhesion barrier is effective at low costs.

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group.

Background: Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups. Methods: The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion. Recommendations: Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention. Discussion: This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited.

In-hospital costs of an admission for adhesive small bowel obstruction.

BACKGROUND: Previous research on the costs of treatment for ASBO is outdated and often based on reimbursements, rather than true healthcare provider costs of the admission and related interventions. An accurate estimate of the true costs of treatment is necessary to understand the healthcare burden and to model cost-efficacy of adhesion strategies. The aim of this study was to provide an accurate cost estimate of the in-hospital costs for treatment of adhesive small bowel obstruction (ASBO) using micro-costing methods. METHODS: Consecutive patients admitted for ASBO to the Radboud University Medical Center from November 2013 to November 2015 were included. An episode of ASBO was defined as an admission for SBO with operative confirmation of adhesions or after radiological exclusion of other causes for SBO. For the purpose of generalization we used the costs of medication and interventions as provided by the Dutch Healthcare Authority and only if these were not available local hospital costs. We evaluated costs separately for operative and non-operative treatment for ASBO. RESULTS: During the study period 39 admissions for ASBO were eligible for analysis. An operative treatment was required in 19 patients (48.7 %). Mean hospital stay for ASBO with operative treatment was 16.0 ± 11 days versus 4.0 ± 2.0 days for non-operative treatment (P = 0.003). A total of 12 patients developed complications, 2 in the non-operative group (10 %) and 10 in the operative group (52.6 %; P = 0.004). Overall costs for an admission for ASBO with operative treatment were €16 305 (SD €2 513), and for non-operative treatment € 2 277 (SD € 265) (p = <0.001). The highest expenditure with operative treatment for ASBO was made for ward stay (mean €7 856, SD €6 882), OR time (mean €2 6845, SD €1 434), ICU stay (mean €2 183, SD €4 305) and (parenteral) feeding costs (mean €1797, SD €2070). A table with correction coefficient to correct for differences in price levels for goods and services between different countries has been added. CONCLUSION: The in-hospital costs of an admission for ASBO are higher than previously thought. These costs can be used to guide hospital reimbursement policy and for the development of a cost-effective model for the use of adhesion barriers.