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Annali Italiani Di Chirurgia 2016Intestinal obstructions/pseudo-obstruction of the small/large bowel are frequent conditions but their management could be challenging. Moreover, a general agreement in...
Clinical strategies for the management of intestinal obstruction and pseudo-obstruction. A Delphi Consensus study of SICUT (Società Italiana di Chirurgia d'Urgenza e del Trauma).
BACKGROUND
Intestinal obstructions/pseudo-obstruction of the small/large bowel are frequent conditions but their management could be challenging. Moreover, a general agreement in this field is currently lacking, thus SICUT Society designed a consensus study aimed to define their optimal workout.
METHODS
The Delphi methodology was used to reach consensus among 47 Italian surgical experts in two study rounds. Consensus was defined as an agreement of 75.0% or greater. Four main topic areas included nosology, diagnosis, management and treatment.
RESULTS
A bowel obstruction was defined as an obstacle to the progression of intestinal contents and fluids generally beginning with a sudden onset. The panel identified four major criteria of diagnosis including absence of flatus, presence of >3.5 cm ileal levels or >6 cm colon dilatation and abdominal distension. Panel also recommended a surgical admission, a multidisciplinary approach, and a gastrografin swallow for patients presenting occlusions. Criteria for immediate surgery included: presence of strangulated hernia, a >10 cm cecal dilatation, signs of vascular pedicles obstructions and persistence of metabolic acidosis. Moreover, rules for non-operative management (to be conducted for maximum 72 hours) included a naso-gastric drainage placement and clinical and laboratory controls each 12 hours. Non-operative treatment should be suspended if any suspects of intra-abdominal complications, high level of lactates, leukocytosis (>18.000/mm3 or Neutrophils >85%) or a doubling of creatinine level comparing admission. Conversely, consensus was not reached regarding the exact timing of CT scan and the appropriateness of colonic stenting.
CONCLUSIONS
This consensus is in line with current international strategies and guidelines, and it could be a useful tool in the safe basic daily management of these common and peculiar diseases.
KEY WORDS
Delphi study, Intestinal obstruction, Large bowel obstruction, Pseudo-obstruction, Small bowel.
Topics: Acidosis; Conservative Treatment; Contrast Media; Delphi Technique; Diatrizoate Meglumine; Disease Management; Emergencies; Emergency Medicine; General Surgery; Hernia; Humans; Intestinal Obstruction; Intestinal Pseudo-Obstruction; Intubation, Gastrointestinal; Laparotomy; Societies, Medical; Stents; Symptom Assessment; Tomography, X-Ray Computed
PubMed: 27179226
DOI: No ID Found -
Journal of Gastrointestinal Surgery :... Jul 2017Small-bowel obstruction is a frequent disorder in emergency medicine and represents a major burden for patients and health care systems worldwide. Within the past years,...
BACKGROUND
Small-bowel obstruction is a frequent disorder in emergency medicine and represents a major burden for patients and health care systems worldwide. Within the past years, progress has been made regarding the management of small-bowel obstructions, including the use of contrast agent swallow as a tool in the decision-making process.
OBJECTIVES
This is a prospective controlled study investigating the central role of contrast agent swallow in the diagnostic and treatment algorithm for small-bowel obstruction at a university department of surgery. Endpoints were the correct identification of patients who needed operative treatment and the accuracy of a conservative treatment decision including the analysis of dropout from this routine algorithm.
METHODS
We performed a single-center analysis of 181 consecutive patients diagnosed with a small-bowel obstruction based on clinical, radiologic, and sonographic findings. Patients with clinical signs of strangulation or peritonitis underwent immediate surgery (group 1). Patients without signs of peritonitis and incomplete stop in the initial abdominal plain film were considered eligible for Gastrografin® challenge (group 2).
RESULTS
Seventy-six of the 181 patients (42.0%) underwent immediate surgery. A Gastrografin® challenge was initialized in 105 of the 181 patients (58.0%). Twenty of these 105 patients (19.1%) with persisting or progressive symptoms and absence of contrast agent in the colon after 12 and 24 h subsequently underwent surgery. Here, a segmental bowel resection was necessary in 6 of these 20 patients (30.0%). In 16 out of 20 patients (80.0%) who failed the Gastrografin® challenge, a corresponding correlate in terms of a strangulation was detected intraoperatively. The Gastrografin® challenge had a specificity of 96% and a sensitivity of 100%; accuracy to predict the need for exploration was 96%.
CONCLUSION
A straightforward algorithm based mainly on contrast agent swallow for patients with small-bowel obstructions enabled a timely and very accurate differentiation between patients qualifying for conservative and operative treatment.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Algorithms; Contrast Media; Diatrizoate Meglumine; Female; Humans; Intestinal Obstruction; Intestine, Small; Male; Middle Aged; Peritonitis; Prospective Studies; Radiography; Sensitivity and Specificity; Treatment Outcome; Young Adult
PubMed: 28409293
DOI: 10.1007/s11605-017-3418-x -
Abdominal Radiology (New York) Nov 2018To evaluate the feasibility and accuracy of remnant small intestinal length measured by barium follow-through (BaFT) examination and three-dimensional CT enterography...
PURPOSE
To evaluate the feasibility and accuracy of remnant small intestinal length measured by barium follow-through (BaFT) examination and three-dimensional CT enterography (CTe).
MATERIALS AND METHODS
Twenty-nine consecutive short bowel syndrome patients (SBS) who underwent BaFT, CTe, and prior surgical measurements of small intestine were included. Measurements of total remnant small intestinal length on BaFT and CTe were compared to surgical measurements using Spearman's rank correlation coefficients, Bland-Altman plots, and paired t test.
RESULTS
The average remnant intestinal length was 73.1 ± 37.2 cm according to surgical measurement. There was a significant positive correlation between CTe and surgical measurement (r = 0.99; p < 0.0001), and a relatively weaker correlation between BaFT and surgical measurement (r = 0.71; p < 0.001). Compared with surgical measurement, the percentage differences of CTe and BaFT were 5.71 ± 6.71% and 27.14 ± 18.41% (mean ± SD), respectively. Furthermore, Bland-Altman plots showed good agreement between CTe and surgical measurement, whereas relatively poor agreement between BaFT and surgical measurement. However, significant difference was found among the three measurement methods by paired t test (p < 0.0001).
CONCLUSIONS
Assessment of remnant small intestinal length by CTe is accurate and acceptable for clinical application, whereas BaFT is less accurate although BaFT is more convenient and cheaper for clinical application. And CTe can provide a cost-effective and noninvasive determination of remnant small intestinal length in planning surgical and nutritional intervention in SBS patients.
Topics: Adolescent; Adult; Aged; Barium Sulfate; Child; Child, Preschool; Contrast Media; Diatrizoate Meglumine; Female; Humans; Imaging, Three-Dimensional; Male; Middle Aged; Prospective Studies; Short Bowel Syndrome; Tomography, X-Ray Computed
PubMed: 29700592
DOI: 10.1007/s00261-018-1597-x -
Radiography (London, England : 1995) Feb 2017
Topics: Acute Kidney Injury; Adenocarcinoma; Aged, 80 and over; Biopsy; Colonic Neoplasms; Colonoscopy; Contrast Media; Diatrizoate; Diatrizoate Meglumine; Enema; Humans; Male; Neoplasm Recurrence, Local; Tomography, X-Ray Computed
PubMed: 28290355
DOI: 10.1016/j.radi.2016.09.005 -
Pediatrics and Neonatology Aug 2014
Topics: Contrast Media; Diatrizoate Meglumine; Enema; Humans; Infant; Infant, Newborn; Intestinal Diseases; Radiography; Renal Elimination
PubMed: 24861535
DOI: 10.1016/j.pedneo.2014.04.004 -
Surgery Jun 2022Small bowel obstruction management has evolved to incorporate the Gastrografin challenge. We expanded its use to the emergency department observation unit, potentially... (Review)
Review
BACKGROUND
Small bowel obstruction management has evolved to incorporate the Gastrografin challenge. We expanded its use to the emergency department observation unit, potentially avoiding hospital admission for highly select small bowel obstruction patients. We hypothesized that the emergency department observation unit small bowel obstruction protocol would reduce admissions, costs, and the total time spent in the hospital without compromising outcomes.
METHODS
We reviewed patients who presented with small bowel obstruction from January 2015 to December 2018. Patients deemed to require urgent surgical intervention were admitted directly and excluded. The emergency department observation unit small bowel obstruction guidelines were introduced in November 2016. Patients were divided into pre and postintervention groups based on this date. The postintervention group was further subclassified to examine the emergency department observation unit patients. Cost analysis for each patient was performed looking at number of charges, direct costs, indirect cost, and total costs during their admission.
RESULTS
In total, 125 patients were included (mean age 69 ± 14.3 years). The preintervention group (n = 62) and postintervention group (n = 63) had no significant difference in demographics. The postintervention group had a 51% (36.7 hours, P < .001) reduction in median duration of stay and a total cost reduction of 49% (P < .001). The emergency department observation unit subgroup (n = 46) median length of stay was 23.6 hours. The readmission rate was 16% preintervention compared to 8% in the postintervention group (P = .18).
CONCLUSION
Management of highly selected small bowel obstruction patients with the emergency department observation unit small bowel obstruction protocol was associated with decreased length of stay and total cost, without an increase in complications, surgical intervention, or readmissions.
Topics: Aged; Aged, 80 and over; Diatrizoate Meglumine; Emergency Service, Hospital; Hospitals; Humans; Intestinal Obstruction; Length of Stay; Middle Aged; Retrospective Studies
PubMed: 34815095
DOI: 10.1016/j.surg.2021.10.041 -
Diseases of the Colon and Rectum Jan 2023Surgical treatment of recurrent rectovaginal fistulas is notoriously difficult. Placement of the gracilis muscle between the vagina and anus is an advanced technique...
BACKGROUND
Surgical treatment of recurrent rectovaginal fistulas is notoriously difficult. Placement of the gracilis muscle between the vagina and anus is an advanced technique used to close persistent fistulas. We have utilized this procedure for recalcitrant fistulas and hypothesized that a gracilis interposition would offer a good treatment option for patients with refractory rectovaginal fistulas, regardless of underlying etiology.
OBJECTIVE
The purpose of this study was to investigate healing rates of gracilis interposition in patients with refractory rectovaginal fistulas.
DESIGN
Following institutional review board approval, a retrospective review of all adult female patients with a diagnosis of rectovaginal fistula between January 2009 and August 2020 was performed; those who underwent gracilis interposition for definitive fistula closure were included for analysis.
SETTINGS
The study was conducted at a colorectal surgery department at a tertiary center in the United States.
PATIENTS
All patients were adult females with a diagnosis of a rectovaginal fistula who underwent gracilis interposition for definitive closure.
MAIN OUTCOME MEASURES
Patient demographics, etiology of rectovaginal fistula, previous surgical intervention, presence of intestinal diversion, operative details, 30-day morbidity, recurrence of fistula, and time to recurrence. Fistula closure was defined as lack of clinical symptoms following stoma closure, negative fistula detection on gastrograffin enema' and absence of an internal opening at examination under anesthesia.
RESULTS
Twenty-two patients were included who had a median age of 43 years (range, 19-64 years) and median body mass index of 31 kg/m 2 (range, 22-51). Median time between prior attempted surgical repair and gracilis surgery was 7 months (range, 3-17). The number of previously attempted repairs were 1-2 (n = 8), 3-4 (n = 9), and > 4 (n = 5). The most recent attempted surgical repair was rectal advancement flap (n = 7), transperineal +/- Martius flap (n = 4), episioproctotomy (n = 3), transvaginal repair (n = 2), and other (n = 6). All patients had fecal diversion at the time of gracilis surgery. Thirty-day postoperative surgical site infection at the graft/donor site was 32% (n = 7). At a median follow-up of 22 months (range 2-62), fistula closure was 59% (n = 13). Gracilis interposition was successful in all inflammatory bowel disease patients.
LIMITATIONS
The study was limited by its retrospective nature.
CONCLUSIONS
Gracilis interposition is an effective operative technique for reoperative rectovaginal fistula closure. Patients should be counseled regarding the possibility of graft/donor site infection. See Video Abstract at http://links.lww.com/DCR/B763 .
REPARACIN CON COLGAJO DE GRACILIS PARA LA FSTULA RECTOVAGINAL REOPERATORIA
ANTECEDENTES:El tratamiento quirúrgico de las fístulas rectovaginales recurrentes es muy difícil. La colocación del músculo gracilis entre la vagina y el ano es una técnica avanzada que se utiliza para cerrar las fístulas persistentes. Hemos utilizado este procedimiento para las fístulas recalcitrantes y planteamos la hipótesis de que una interposición del gracilis ofrecería una buena opción de tratamiento para pacientes con fístulas rectovaginales refractarias, independientemente de la etiología subyacente.OBJETIVO:Investigar las tasas de curación de la interposición del gracilis en pacientes con fístulas rectovaginales refractarias.DISEÑO:Tras la aprobación de la junta de revisión institucional, se realizó una revisión retrospectiva de todas las pacientes adultas con un diagnóstico de fístula rectovaginal entre enero de 2009 y agosto de 2020; los que se sometieron a interposición de gracilis para el cierre definitivo de la fístula se incluyeron para el análisis.AJUSTE:Departamento de cirugía colorrectal de un centro terciario en Estados Unidos.PACIENTES:Todas las pacientes adultas con diagnóstico de fístula rectovaginal que se sometieron a interposición de gracilis para cierre definitivo.PRINCIPALES MEDIDAS DE RESULTADO:datos demográficos del paciente, etiología de la fístula rectovaginal, intervención quirúrgica previa, presencia de derivación intestinal, detalles quirúrgicos, morbilidad a los 30 días, recurrencia de la fístula y tiempo hasta la recurrencia. El cierre de la fístula se definió como la ausencia de síntomas clínicos después del cierre del estoma, la detección negativa de la fístula en el enema de gastrograffin y la ausencia de una abertura interna en el examen bajo anestesia.RESULTADOS:Se incluyeron 22 pacientes que tenían una mediana de edad de 43 años (rango 19-64 años) y una mediana de índice de masa corporal de 31 kg / m2 (rango 22-51). La mediana de tiempo entre el intento previo de reparación quirúrgica y la cirugía del gracilis fue de 7 meses (rango 3-17). El número de reparaciones previamente intentadas fue: 1-2 (n = 8), 3-4 (n = 9), y >4 (n = 5). El intento de reparación quirúrgica más reciente fue el colgajo de avance rectal (n = 7), el colgajo transperineal +/- Martius (n = 4), la episioproctotomía (n = 3), la reparación transvaginal (n = 2) y otros (n = 6). Todos los pacientes tenían derivación fecal en el momento de la cirugía gracilis. La infección del sitio quirúrgico posoperatorio a los 30 días en el sitio del injerto / donante fue del 32% (n = 7). Con una mediana de seguimiento de 22 meses (rango 2-62), el cierre de la fístula fue del 59% (n = 13). La interposición de Gracilis fue exitosa en todos los pacientes con enfermedad inflamatoria intestinal.LIMITACIONES:Carácter retrospectivo de los datos.CONCLUSIONES:La interposición de Gracilis es una técnica quirúrgica eficaz para el cierre reoperatorio de la fístula rectovaginal. Se debe asesorar a los pacientes sobre la posibilidad de infección del sitio del injerto / donante. Consulte Video Resumen en http://links.lww.com/DCR/B763 . (Traducción-Dr. Ingrid Melo ).
Topics: Adult; Humans; Female; Young Adult; Middle Aged; Retrospective Studies; Rectovaginal Fistula; Diatrizoate Meglumine; Rectal Fistula; Anal Canal; Vaginal Fistula
PubMed: 34759248
DOI: 10.1097/DCR.0000000000002249 -
Journal of Gastroenterology and... Jan 2022We had previously reported that the administration of Gastrografin through a nasogastric tube (NGT-G) followed by long tube (LT) strategy could be a novel standard... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
We had previously reported that the administration of Gastrografin through a nasogastric tube (NGT-G) followed by long tube (LT) strategy could be a novel standard treatment for adhesive small bowel obstruction (ASBO); however, the long-term outcomes after initial improvement remain unknown. This study aimed to analyze the long-term outcomes of first-line NGT-G.
METHODS
Enrolled patients with ASBO were randomly assigned to receive LT or NGT-G between July 2016 and November 2018. Thereafter, the cumulative surgery rate, cumulative recurrence rate, and overall survival (OS) rate were analyzed. In addition, subset analysis was conducted to determine the cumulative recurrence rate according to colonic contrast with Gastrografin at 24 h.
RESULTS
A total of 223 patients (LT group, n = 111; NGT-G group, n = 112) were analyzed over a median follow-up duration of 550 days. The cumulative 1-year surgery rates, cumulative 1-year recurrence rates, and 1-year OS rates in the LT and NGT-G groups were 18.8% and 18.1%, 30.0% and 31.7%, and 99.1% and 96.6%, respectively; no significant differences were observed between both groups. In the NGT-G group, a negative colonic contrast at 24 h demonstrated a higher tendency for future recurrence compared with a positive colonic contrast at 24 h (1-year recurrence rate: negative contrast, 46.9% vs positive contrast, 27.6%).
CONCLUSIONS
Gastrografin through a nasogastric tube followed by LT can be a promising treatment strategy for ASBO, with long-term efficacies equivalent to initial LT placement.
Topics: Contrast Media; Diatrizoate Meglumine; Humans; Intestinal Obstruction; Intestine, Small; Intubation, Gastrointestinal; Tissue Adhesions; Treatment Outcome
PubMed: 34478173
DOI: 10.1111/jgh.15681 -
Cell Biochemistry and Biophysics Sep 2014To study the clinical and diagnostic significance of enteroclysis through nasointestinal decompression intubation, thirty-five patients with small bowel obstruction were...
To study the clinical and diagnostic significance of enteroclysis through nasointestinal decompression intubation, thirty-five patients with small bowel obstruction were enrolled. A nasointestinal catheter of 300 cm was placed through the nasal cavity then pushed to the upper jejunum under X-ray realtime monitoring. The patients underwent intra-small-intestinal suction therapy reducing or relieving the obstruction after 3 days. As the catheter reached the lesions, we conducted selective imaging. Using fluoroscopy, we injected 20-100 ml meglumine diatrizoate 76 % and 50-200 ml air via the decompression suction port to produce a double-contrast radiography. The catheter was then retrieved to the upper jejunum, and the X-ray of the small intestine was obtained. All 35 patients had successful intubations. The decompression treatment resolved symptoms in 20 cases and alleviated symptoms in 15 cases. Ten cases underwent surgery. The images obtained by infusing meglumine diatrizoate through the decompression catheter were of good quality. Among the 35 cases, six were absent of any distinct abnormal signs on the X-ray, 15 had adhesive ileus, four had small bowel tumor (three metastatic tumor, one small bowel cancer), three had Crohn's disease, three had radiation enteritis (one of the three was mistaken for small bowel metastatic tumor), two had enteric intussusception, one had a polyp in the small intestine, one had ascending colon cancer. The nasointestinal decompression intubation under X-ray monitoring serves a dual function for patients with intestine obstruction, by decompressing the small bowel and examining the small intestinal radiographically. The X-rays can confirm the obstruction and provide guidelines for surgery.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Catheters; Decompression, Surgical; Female; Humans; Intestinal Obstruction; Intestines; Intubation; Male; Middle Aged; Nose; Radiography; Young Adult
PubMed: 24715234
DOI: 10.1007/s12013-014-9919-2 -
Pediatrics and Neonatology Aug 2014When abdominal distention occurs or bowel obstruction is suspected in the neonatal period, a water-soluble contrast enema is helpful for diagnostic and therapeutic...
BACKGROUND
When abdominal distention occurs or bowel obstruction is suspected in the neonatal period, a water-soluble contrast enema is helpful for diagnostic and therapeutic purposes. The water-soluble contrast medium is evacuated through the anus as well as excreted via the kidneys in some babies. This study was designed to evaluate the incidence of renal excretion after enemas using water-soluble contrast media and presume the causes.
METHODS
Contrast enemas using diluted water-soluble contrast media were performed in 23 patients under 2 months of age. After the enema, patients were followed with simple abdominal radiographs to assess the improvement in bowel distention, and we could also detect the presence of renal excretion of contrast media on the radiographs. Reviewing the medical records and imaging studies, including enemas and consecutive abdominal radiographs, we evaluated the incidence of renal excretion of water-soluble contrast media and counted the stay duration of contrast media in urinary tract, bladder, and colon.
RESULTS
Among 23 patients, 12 patients (52%) experienced the renal excretion of water-soluble contrast media. In these patients, stay-in-bladder durations of contrast media were 1-3 days and stay-in-colon durations of contrast media were 1-10 days, while stay-in-colon durations of contrast media were 1-3 days in the patients not showing renal excretion of contrast media. The Mann-Whitney test for stay-in-colon durations demonstrated the later evacuation of contrast media in the patients with renal excretion of contrast media (p = 0.07). The review of the medical records showed that 19 patients were finally diagnosed as intestinal diseases, including Hirschsprung's disease, meconium ileum, meconium plug syndrome, and small bowel atresia or stenosis. Fisher's exact test between the presence of urinary excretion and intestinal diseases indicated a statistically significant difference (p = 0.04).
CONCLUSION
The intestinal diseases causing bowel obstruction may increase the water-soluble contrast media's dwell time in the bowel and also increase urinary excretion.
Topics: Contrast Media; Diatrizoate Meglumine; Enema; Female; Hirschsprung Disease; Humans; Infant, Newborn; Intestinal Atresia; Intestinal Diseases; Intestine, Small; Male; Meconium; Radiography, Abdominal; Renal Elimination
PubMed: 24295782
DOI: 10.1016/j.pedneo.2013.07.012