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Current Gastroenterology Reports Jun 2017This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy. (Review)
Review
PURPOSE OF REVIEW
This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy.
RECENT FINDINGS
SBO incidence is about 350,000/annum in the USA. Etiologies include adhesions (65%), hernias (10%), neoplasms (5%), Crohn's disease (5%), and other (15%). Bowel dilatation occurs proximal to obstruction primarily from swallowed air and secondarily from intraluminal fluid accumulation. Dilatation increases mural tension, decreases mucosal perfusion, causes bacterial proliferation, and decreases mural tensile strength that increases bowel perforation risks. Classical clinical tetrad is abdominal pain, nausea and emesis, abdominal distention, and constipation-to-obstipation. Physical exam may reveal restlessness, acute illness, and signs of dehydration and sepsis, including tachycardia, pyrexia, dry mucous membranes, hypotension/orthostasis, abdominal distention, and hypoactive bowel sounds. Severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness suggest advanced SBO, as do marked leukocytosis, neutrophilia, bandemia, and lactic acidosis. Differential diagnosis includes postoperative ileus, narcotic bowel, colonic pseudo-obstruction, mesenteric ischemia, and large bowel obstruction. Medical resuscitation includes intravenous hydration, correcting electrolyte abnormalities, intravenous antibiotics, nil per os, and nasoenteral suction. Abdominal CT with oral and intravenous gastrografin contrast is highly sensitive and specific in detecting/characterizing SBO. SBO usually resolves with medical therapy but requires surgery, preferentially by laparoscopy, for unremitting total obstruction, bowel perforation, severe ischemia, or clinical deterioration with medical therapy. Overall mortality is 10% but increases to 30% with bowel necrosis/perforation. Key point in SBO is early diagnosis, emphasizing abdominal CT; aggressive medical therapy including rehydration, antibiotics, and nil per os; and surgery for failed medical therapy.
Topics: Abdominal Pain; Diagnosis, Differential; Dilatation, Pathologic; Humans; Ileus; Intestinal Obstruction; Intestine, Small; Laparoscopy; Nausea; Physical Examination; Postoperative Complications; Vomiting
PubMed: 28439845
DOI: 10.1007/s11894-017-0566-9 -
European Urology Oct 2013Postoperative paralytic ileus (POI) has profound clinical consequences because it represents a substantial burden on both patients and health care resources. (Review)
Review
CONTEXT
Postoperative paralytic ileus (POI) has profound clinical consequences because it represents a substantial burden on both patients and health care resources.
OBJECTIVE
To determine the knowledge base regarding POI in the radical cystectomy (RC) population with an emphasis on preventive measures and risk factors.
EVIDENCE ACQUISITION
A systematic literature search of Medline (1966 to February 2011) and a study review were conducted. Eligible studies explicitly reported the incidence of POI and/or at least two quantitative measures of gastrointestinal recovery.
EVIDENCE SYNTHESIS
The search identified 727 relevant articles; 77 met eligibility criteria, comprising 13 793 patients. Of these, 21 used explicit definitions of POI, and they varied widely. Across studies, the incidence of POI ranged from 1.58% to 23.5%. Possible risk factors for POI included increasing age and body mass index. Seventeen studies reported effects of an intervention on POI: 3 randomized controlled studies, 11 observational cohort studies with concurrent comparison, and 3 observational cohort studies with nonconcurrent comparison. Gum chewing was associated with shortened times to flatus (2.4 vs 2.9 d; p<0.0001) and bowel movement (BM) (3.2 vs 3.9 d; p<0.001) in one observational cohort study (n=102); omission of a postoperative nasogastric tube (NGT) was associated with shorter time to flatus (4.21 vs 5.33 d; p=0.0001) and shorter length of stay (14.4 vs 19.1 d; p=0.001) in one observational cohort study (n=430); and the routine use of bowel preparation was associated with an increased incidence of POI (5% vs 19%) in another series (n=86). Additionally, readaptation of the dorsolateral peritoneal layer was shown to shorten times to flatus (p=0.016) and times to BM (p=0.011) in one randomized controlled study (n=200).
CONCLUSIONS
The incidence/definition of POI after RC is highly variable. An improved reporting strategy is needed to identify true incidence and risk factors, and to guide future research for both potential preventive and therapeutic interventions.
Topics: Age Factors; Body Mass Index; Cystectomy; Humans; Incidence; Intestinal Pseudo-Obstruction; Recovery of Function; Risk Factors; Terminology as Topic; Time Factors; Treatment Outcome
PubMed: 23245816
DOI: 10.1016/j.eururo.2012.11.051 -
International Journal of Surgery... Mar 2024Postoperative paralytic ileus (POI) is a significant concern following gastrointestinal tumor surgery. Effective preventive and therapeutic strategies are crucial but...
BACKGROUND
Postoperative paralytic ileus (POI) is a significant concern following gastrointestinal tumor surgery. Effective preventive and therapeutic strategies are crucial but remain elusive. Current evidence from randomized-controlled trials on pharmacological interventions for prevention or treatment of POI are systematically reviewed to guide clinical practice and future research.
MATERIALS AND METHODS
Literature was systematically searched for prospective randomized-controlled trials testing pharmacological interventions for prevention or treatment of POI after gastrointestinal tumor surgery. Meta-analysis was performed using a random effects model to determine risk ratios and mean differences with 95% confidence intervals. Risk of bias and evidence quality were assessed.
RESULTS
Results from 55 studies, involving 5078 patients who received experimental interventions, indicate that approaches of opioid-sparing analgesia, peripheral opioid antagonism, reduction of sympathetic hyperreactivity, and early use of laxatives effectively prevent POI. Perioperative oral Alvimopan or intravenous administration of Lidocaine or Dexmedetomidine, while safe regarding cardio-pulmonary complications, demonstrated effectiveness concerning various aspects of postoperative bowel recovery (Lidocaine: -5.97 [-7.20 - -4.74]h, P<0.0001; Dexmedetomidine: -13.00 [-24.87 - -1.14]h, P=0.03 for time to first defecation; Alvimopan: -15.33 [-21.22 - -9.44]h, P<0.0001 for time to GI-2) and length of hospitalization (Lidocaine: -0.67 [-1.24 - -0.09]d, P=0.02; Dexmedetomidine: -1.28 [-1.96 - -0.60]d, P=0.0002; Alvimopan: -0.58 [-0.84 - -0.32]d, P<0.0001) across wide ranges of evidence quality. Perioperative non-opioid analgesic use showed efficacy concerning bowel recovery as well as length of hospitalization (-1.29 [-1.95 - -0.62]d, P=0.0001). Laxatives showed efficacy regarding bowel movements, but not food tolerance and hospitalization. Evidence supporting pharmacological treatment for clinically evident POI is limited. Results from one single study suggest that Neostigmine reduces time to flatus and accelerates bowel movements (-37.06 [-40.26 - -33.87]h, P<0.0001 and -42.97 [-47.60 - -38.35]h, P<0.0001, respectively) with low evidence quality.
CONCLUSION
Current evidence concerning pharmacological prevention and treatment of POI following gastrointestinal tumor surgery is limited. Opioid-sparing concepts, reduction of sympathetic hyperreactivity, and laxatives should be implemented into multimodal perioperative approaches.
PubMed: 38526522
DOI: 10.1097/JS9.0000000000001393 -
World Journal of Surgery Dec 2009Postoperative ileus has long been considered an inevitable consequence of gastrointestinal surgery. It prolongs hospital stay, increases morbidity, and adds to treatment... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Postoperative ileus has long been considered an inevitable consequence of gastrointestinal surgery. It prolongs hospital stay, increases morbidity, and adds to treatment costs. Chewing is a form of sham feeding reported to stimulate bowel motility. This analysis examines the value of chewing-gum therapy in treatment of postoperative ileus.
METHODS
A search for randomized, controlled trials studying elective gastrointestinal surgery was undertaken using MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists. Outcomes were extracted including time to first flatus and bowel motion, length of stay, and complications. Statistical analysis was undertaken using the weighted mean difference (WMD) and random-effects model with 95% confidence intervals (CI).
RESULTS
Seven studies with 272 patients were included. For time to first flatus the analysis favored treatment with a WMD of 12.6 h (17%) reduction (95% CI -21.49 to -3.72; P = 0.005). For time to first bowel motion, treatment was favored with a WMD of 23.11 h (22%) reduction (95% CI -34.32 to -11.91; P < 0.001). For length of stay, the analysis showed a nonsignificant trend toward treatment with WMD of 23.88 h (12%) reduction (95% CI -53.29 to +5.53; P = 0.11). There were no significant differences in complication rates.
CONCLUSIONS
Chewing-gum therapy following open gastrointestinal surgery is beneficial in reducing the period of postoperative ileus, although without a significant reduction in length of hospital stay. These outcomes are not significant for laparoscopic gastrointestinal surgery.
Topics: Chewing Gum; Clinical Trials as Topic; Digestive System Surgical Procedures; Humans; Intestinal Pseudo-Obstruction; Mastication
PubMed: 19763686
DOI: 10.1007/s00268-009-0104-5 -
International Journal of Surgery... Apr 2009An important cause of delayed recovery from intestinal surgery is postoperative ileus. Gum chewing is a form of sham feeding, which could encourage gastrointestinal... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
An important cause of delayed recovery from intestinal surgery is postoperative ileus. Gum chewing is a form of sham feeding, which could encourage gastrointestinal motility through cephalic-vagal stimulation.
METHODS
We sought to identify all randomized controlled trials comparing gum chewing with standard care after elective intestinal surgery. We searched electronic databases (Cochrane, Embase, and PubMed), reference lists and contacted authors to obtain further data. We assessed the identified trials for quality and performed a meta-analysis and systematic review. The main outcome measures examined were time to flatus and stool postoperatively and length of hospital stay, which were analysed using random effect models. We also examined clinical complication rates.
RESULTS
We identified nine eligible trials that had enrolled a total of 437 patients. The intervention was well tolerated and complication rates were low. There was statistical evidence of heterogeneity for the three main outcomes. Pooled estimates showed a reduction in time to flatus by 14 h (95% CI: -20 to -8h, p=0.001), time to bowel movement by 23 h (95% CI: -32 to -15 h, p<0.001) and a reduction in length of hospital stay by 1.1 days (95% CI: -1.9 to -0.2 days, p=0.016).
CONCLUSIONS
Chewing sugarless gum following elective intestinal resection is associated with improved outcomes. Insufficient data were available to demonstrate a reduced rate of clinical complications or reduced cost. An adequately powered, methodologically rigorous trial of gum chewing is required to confirm if there are any benefits and if these result in differences in clinical outcomes such as infection.
Topics: Aged; Chewing Gum; Child; Gastrointestinal Motility; Humans; Intestinal Pseudo-Obstruction; Mastication; Middle Aged; Postoperative Complications; Randomized Controlled Trials as Topic
PubMed: 19261555
DOI: 10.1016/j.ijsu.2009.01.006 -
Autonomic Neuroscience : Basic &... Nov 2022Autonomic dysfunction has been occasionally described in varicella-zoster virus (VZV) infection, while few systematic reviews are available. We systematically review... (Review)
Review
BACKGROUND AND PURPOSE
Autonomic dysfunction has been occasionally described in varicella-zoster virus (VZV) infection, while few systematic reviews are available. We systematically review autonomic dysfunction due to VZV infection.
METHODS
This study followed the PRISMA guideline, and three databases were researched and included cross-sectional studies in full-length publications in the English language using appropriate search keywords.
RESULTS
A total of 102 articles were identified initially; finally 45 studies were used for review, comprising pupillomotor dysfunction in 4, sudomotor dysfunction in 2, cardiovascular dysfunction in 2, gastrointestinal dysfunction in 14, and urogenital dysfunction in 23. They can be summarized as (1) VZV infection rarely produces orthostatic hypotension, which involves diffuse sympathetic dysfunction by polyneuropathy. (2) In contrast, VZV infection produces dysfunction of the bladder and the bowel, which involves segmental parasympathetic or sympathetic dysfunction by dorsal root ganglionopathy.
CONCLUSIONS
Awareness of VZV-related autonomic dysfunction is important, because such patients may first visit a gastroenterology or urology clinic. Close collaboration among neurologists, dermatologists, gastroenterologists, and urologists is important to start early antiviral agents and maximize bowel and bladder care in such patients.
Topics: Autonomic Nervous System Diseases; Chickenpox; Cross-Sectional Studies; Herpes Zoster; Herpesvirus 3, Human; Humans
PubMed: 35863181
DOI: 10.1016/j.autneu.2022.103018 -
Therapeutic Advances in Urology 2023Urothelial carcinoma can arise from the urinary bladder or from the upper urinary tract. In some instances, urinary bladder cancer (UBC) and upper tract urothelial... (Review)
Review
INTRODUCTION
Urothelial carcinoma can arise from the urinary bladder or from the upper urinary tract. In some instances, urinary bladder cancer (UBC) and upper tract urothelial carcinoma (UTUC) can be concurrently diagnosed, necessitating a combined radical cystectomy (RC) with radical nephroureterectomy (RNU). A systematic review was done on the combined procedure exploring outcomes and indications, in addition to a comparative analysis between the combined procedure and cystectomy alone.
METHODS
For the systematic review, three databases (Embase, PubMed, and Cochrane) were queried, selecting only studies that included intraoperative and perioperative data. For the comparative analysis, using the NSQIP database, CPT codes for RC and RNU were used to identify two cohorts, one with RC and RNU and one with RC alone. A descriptive analysis was performed on all preoperative variables, and propensity score matching (PSM) was performed. Postoperative events were then compared between the two matched cohorts.
RESULTS
For the systematic review, 28 relevant articles were included amounting to 947 patients who underwent the combined procedure. The most common indication was synchronous multifocal disease, the most common approach was open surgery, and the most common diversion technique was using an ileal conduit. Almost 28% of patients required blood transfusion and remained in the hospital for an average of 13 days. The most common postoperative complication was prolonged paralytic ileus. For the comparative analysis, 11,759 patients were included of which 97.5% underwent RC only and 2.5% underwent the combined procedure. After PSM, the cohort that had undergone the combined procedure showed an increased risk of renal injury, increased readmission rates, and increased reoperation rates. Whereas the cohort that had undergone RC only showed an increased risk of deep venous thrombosis (DVT), sepsis, or septic shock.
CONCLUSION
A combined RC and RNU is a treatment option for concurrent UCB and UTUC that should be cautiously utilized as it is associated with high morbidity and mortality. Patient selection, discussion of the risks and benefits of the procedure, and explanation of the available treatment options remain the most important pillars in managing patients with this complex disease.
PubMed: 37188157
DOI: 10.1177/17562872231171757 -
European Journal of Vascular and... Jul 2013The aim was to systematically review and meta-analyse the differences between the retroperitoneal (RP) and the transperitoneal (TP) approach to the infrarenal abdominal... (Comparative Study)
Comparative Study Meta-Analysis Review
OBJECTIVES
The aim was to systematically review and meta-analyse the differences between the retroperitoneal (RP) and the transperitoneal (TP) approach to the infrarenal abdominal aorta.
DESIGN
Systematic review and meta-analysis.
METHODS
PubMed, the Cochrane library, Embase and ClinicalTrials.gov were searched for all studies on differences in clinical outcomes between the RP and TP approach. Outcomes were selected based on inclusion in two or more studies: Operative (length of procedure, intraoperative blood loss); Post operative complications (paralytic ileus, pneumonia, myocardial infarction (MI), renal failure and wound hernia); Mortality (30 day, 1 year); Post-operative changes in respiratory function (forced expiratory volume in 1 second, forced vital capacity); Length of hospital and Intensive care unit (ICU) stay and Cost. The data were pooled by outcome.
RESULTS
Eight randomised and 21 cohort studies involving 3035 patients were included. Meta-analysis showed significantly lower rates of postoperative ileus (Odds ratio (OR) 0.17[95% CI 0.10, 0.32] p < 0.00001), pneumonia (OR 0.42[95% CI 0.26, 0.68] p = 0.0004), ICU stay (standardised mean difference (SMD) 0.67[95% CI 1.28, 0.06] p = 0.03), total hospital stay (SMD 0.88[95% CI 1.32, 0.44] p < 0.0001) and cost (SMD 1.15[95% CI 2.11, 0.19] p = 0.02) for patients undergoing a RP approach. Study quality was generally low, with conflicting results and concerns over publication bias in some cohort studies.
CONCLUSIONS
The RP approach for open aortic surgery is associated with lower rates of postoperative ileus and pneumonia when compared to the TP approach.
Topics: Aortic Aneurysm, Abdominal; Humans; Postoperative Complications; Retroperitoneal Space; Vascular Surgical Procedures
PubMed: 23590870
DOI: 10.1016/j.ejvs.2013.03.018 -
Cureus Sep 2022Acute appendicitis is one of the most commonly encountered surgical emergencies worldwide. The laparoscopic approach for managing acute appendicitis is gaining... (Review)
Review
Acute appendicitis is one of the most commonly encountered surgical emergencies worldwide. The laparoscopic approach for managing acute appendicitis is gaining popularity over open appendicectomy in the current surgical practice. The advantages of laparoscopic appendectomy are early recovery, fewer wound complications, less pain and better cosmesis. One of the most critical steps in laparoscopic appendicectomy is a secure appendicular stump closure. Life-threatening postoperative complications are often encountered following the breakdown of appendicular stump closure. There are several methods to achieve appendicular stump closure such as intra-corporeal knotting, endoloops, external corporeal knotting and pushing knot inside, endoscopic linear cutting stapler (endo GIA), and endoclips. A meta-analysis on the technique of appendicular stump closure in laparoscopic appendicectomy failed to demonstrate the superiority of one method over the other. In the last few years, many authors have evaluated the outcome of sutureless appendicectomy performed using devices like a harmonic scalpel. This systematic review and meta-analysis is aimed to summarise the current evidence regarding the utility and safety of harmonic scalpel in sutureless appendicectomy. This systematic review and meta-analysis was conducted as per the preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. A systematic, detailed search was carried out by the authors in the electronic database, including Medline, Embase, CENTRAL, Scopus, Google scholar and clinical trial registry. Studies were selected and compared based on outcomes such as operative time, hospital stay, postoperative paralytic ileus, wound infection, and total complications. Statistical analysis was performed using the random effect model, fixed-effect model, pooled risk ratio, pooled mean difference and I heterogeneity. Four comparative studies with a total of 642 patients (376 male and 266 females) were included in the analysis. There were 359 patients in the conventional technique of appendicular stump closure group and 283 patients in the harmonic scalpel for appendicular stump closure group. Pooled analysis of the outcome measure of total complications showed that the use of harmonic scalpel for closure of appendiceal stump does not result in an increased incidence of complications as compared to the conventional technology of appendiceal stump closure. Pooled analysis of the outcome measure of mean operative time revealed a statistically significant reduction in the operative time in the patients where harmonic scalpel has been used for the management of appendiceal stump as compared to conventional methods (pooled mean difference of -12.96 with 95% CI -15.42, -10.50). Appendiceal stump closure during laparoscopic appendectomy by harmonic scalpel (HS) is comparable with the conventional techniques in terms of hospital stay, wound infection, postoperative paralytic ileus, and total complications. The use of a harmonic scalpel for closure of appendicular stump is associated with a reduction of the mean operative time of laparoscopic appendicectomy.
PubMed: 36159348
DOI: 10.7759/cureus.28759 -
The British Journal of Surgery Mar 2009Acute colonic pseudo-obstruction is characterized by clinical and radiological evidence of acute large bowel obstruction in the absence of a mechanical cause. The... (Review)
Review
BACKGROUND
Acute colonic pseudo-obstruction is characterized by clinical and radiological evidence of acute large bowel obstruction in the absence of a mechanical cause. The condition usually affects elderly people with underlying co-morbidities, and early recognition and appropriate management are essential to reduce the occurrence of life-threatening complications.
METHODS
A part-systematic review was conducted. This was based on key publications focusing on advances in management.
RESULTS AND CONCLUSIONS
Although acute colonic dilatation has been suggested to result from a functional imbalance in autonomic nerve supply, there is little direct evidence for this. Other aetiologies derived from the evolving field of neurogastroenterology remain underexplored. The rationale of treatment is to achieve prompt and effective colonic decompression. Initial management includes supportive interventions that may be followed by pharmacological therapy. Controlled clinical trials have shown that the acetylcholinesterase inhibitor neostigmine is an effective treatment with initial response rates of 60-90 per cent; other drugs for use in this area are in evolution. Colonoscopic decompression is successful in approximately 80 per cent of patients, with other minimally invasive strategies continuing to be developed. Surgery has thus become largely limited to those in whom complications occur. A contemporary management algorithm is provided on this basis.
Topics: Acute Disease; Cecostomy; Colonic Pseudo-Obstruction; Colonoscopy; Decompression, Surgical; Humans; Neostigmine; Parasympathomimetics; Radiography, Interventional; Tomography, X-Ray Computed
PubMed: 19224517
DOI: 10.1002/bjs.6480