Evaluation of a water-soluble contrast protocol for nonoperative management of pediatric adhesive small bowel obstruction

Background/purpose

We examined outcomes before and after implementing an enteral water-soluble contrast protocol for management of pediatric adhesive small bowel obstruction (ASBO).

粘连性小肠梗阻的长期随访和危险因素分析

目的 比较手术和保守治疗粘连性小肠梗阻的长期随访效果。方法 回顾性分析及随访南京军区南京总医院解放军普通外科研究所自2001年1月至2006年6月诊断为粘连性小肠梗阻的150例病人的临床资料。结果 150例病人住院162例次,手术治疗119例次（73.5%）,保守治疗43例次（26.5%）。手术治疗组平均缓解时间为（64.5±2.1）个月,5年累积复发率为（18±5）%;保守治疗组平均缓解时间为（54.0±4.6）个月,5年累积复发率（32%±8%）,组间差异具有统计学意义（P＝0.020）。未发现其他危险因素对肠梗阻复发有影响。结论 对于粘连性小肠梗阻,手术治疗较保守治疗更能减少肠梗阻的复发。但本研究为非对照研究,不能完全避免组间差异。     

Randomized controlled trial of Gastrografin in adhesive small bowel obstruction

BACKGROUND: Several previous studies have shown that Gastrografin can be utilized to triage patients with adhesive small bowel obstruction (ASBO) to an operative or a non-operative course. Previous studies assessing the therapeutic effect of Gastrografin have been confounded by post-administration radiology alerting the physician to the treatment group of the patient. Therefore the aim of the present paper was to test the hypothesis that Gastrografin hastens the non-operative resolution of (ASBO). METHODS: Patients, diagnosed with ASBO on clinical and radiological grounds, were randomized to receive Gastrografin or placebo in a double-blinded fashion. Patients did not undergo further radiological investigation. If the patient required subsequent radiological intervention or surgical intervention they were excluded from the study. End-points were passage of time to resolution of ASBO (flatus and bowel motion), length of hospital stay and complications. RESULTS: Forty-five patients with ASBO were randomized to receive either Gastrografin or placebo. Two patients were excluded due to protocol violations. Four patients in each group required surgery. Eighteen of the remaining patients received Gastrografin and 17 received placebo. Patients who received Gastrografin had complete resolution of their ASBO significantly earlier than placebo patients (12 vs 21 h, P = 0.009) and this translated into a median of a 1-day saving in time in hospital (3 vs 4 days, P = 0.03). CONCLUSIONS: Gastrografin accelerates resolution of ASBO by a specific therapeutic effect.     

Prospective evaluation of oral gastrografin in postoperative small bowel obstruction

BACKGROUND: Orally administered gastrografin has been used for early resolution of postoperative small bowel obstruction (POSBO) and to reduce the need for surgery in various studies. However the studies have reported conflicting results as patients with complete obstruction and equivocal diagnosis of bowel strangulation were also included. PATIENTS AND METHODS: We carried out a prospective study to evaluate the efficacy of gastrografin in patients with partial adhesive small bowel obstruction. Patients with suspected strangulation, complete obstruction, obstructed hernia, bowel malignancy, and radiation enteritis were excluded. Sixty-two patients with partial adhesive small bowel obstruction were given an initial trial of conservative management of 48 h. Thirty-eight patients improved within 48 h and the other 24 were given 100 ml of undiluted gastrografin through the nasogastric tube. In 22 patients the contrast reached the colon within 24 h. In the remaining two patients the contrast failed to reach the colon and these underwent surgery. RESULTS: The use of gastrografin avoided surgical intervention in 91.3% (22 of 24) patients who failed conservative management of POSBO. Gastrografin also decreased the overall requirement for surgical management of POSBO from the reported rate of 25 to 30% to 3.2% (2 of 62). CONCLUSION: Use of gastrografin in patients with partial POSBO helps in resolution of symptoms and avoids the need for surgical management in the majority of patients.     

Role of Gastrografin in assigning patients to a non-operative course in adhesive small bowel obstruction

BACKGROUND: Adhesive small bowel obstruction (SBO) is a common surgical emergency. Water soluble contrast agents have been used to identify patients who might be treated non-operatively rather than operatively. The present study was designed to audit the introduction of such use of Gastrografin contrast into clinical practice. METHOD: Patients presenting acutely to hospital with clinically suspected and radiologically proven SBO were entered in the study. As soon as practicable, 100 mL of undiluted Gastrografin was given either orally or by the nasogastric tube (which was then spigotted). After 4 h, a plain supine abdominal X-ray (AXR) was taken. If the contrast was seen in the large bowel, and there had been no deterioration in the patient's condition, then non-operative treatment was continued. If the contrast remained in the small bowel, a clinical judgement was made as to whether to proceed with operative intervention. A group of historical controls were obtained by a retrospective review of the hospital medical records through data obtained from the Department of General Surgery Audit System. RESULTS: Twenty-five patients were entered into the study. In 20 of these patients the contrast was seen to arrive in the large bowel at 4 h. All of these patients completed a non-operative course to full recovery. In another two patients a successful decision was made to pursue a non-operative management strategy. These 22 patients had a mean hospital stay of 3.9 days. Eighty historical controls had successfully completed a non-operative course for SBO. They had a mean hospital stay of 5.6 days. This was significantly longer than that of the Gastrografin group (P < 0.016, t-test). CONCLUSION: This paper has demonstrated that undiluted Gastrografin may be safely used to assign patients to a non-operative management plan and this results in a decreased hospital stay.     

Adhesive small bowel adhesions obstruction: Evolutions in diagnosis,management and prevention

Intra-abdominal adhesions following abdominal surgery represent a major unsolved problem. They are the first cause of small bowel obstruction. Diagnosis is based on clinical evaluation, water-soluble contrast followthrough and computed tomography scan. For patients presenting no signs of strangulation, peritonitis or severe intestinal impairment there is good evidence to support non-operative management. Open surgery is the preferred method for the surgical treatment of adhesive small bowel obstruction, in case of suspected strangulation or after failed conservative management, but laparoscopy is gaining widespread acceptance especially in selected group of patients. "Good" surgical technique and anti-adhesive barriers are the main current concepts of adhesion prevention. We discuss current knowledge in modern diagnosis and evolving strategies for management and prevention that are leading to stratified care for patients.     

Adhesional small bowel obstruction after colorectal surgery

BACKGROUND: Acute clinical indicators of complications in colorectal surgery can be readily attained but it is much harder to gather indicators of long-term outcomes such as small bowel obstruction (SBO). However, with improved in-hospital data collection and coding such information is becoming available. The aim of the present study was to examine our own hospital database for SBO rates post-colorectal surgery. METHODS: The database was searched and then the relevant medical records were reviewed of all patients admitted to Flinders Medical Centre (Bedford Park, Australia) between July 1999 and November 2002 with a diagnosis of SBO following a colorectal procedure during this same time period. RESULTS: There were 21 patients that accounted for 28 readmissions from a total colorectal procedure group of 583 patients. The arbitrary subgroups were: 13/325 (4%) for colonic resections; 7/186 (3.7%) for rectal resections; 0/12 (0%) for laparotomies/other procedures; and 1/39 (2.6%) for stoma formation/reversals. The overall SBO rate requiring readmission was therefore 3.6%/pt in the 3 years. There was a large variation in the first readmission interval, 38% occurred within 3 months, 43% between 3 and 12 months, and 19% after 1 year. At the first readmission 38% of patients had operative treatment. The mean length of stay was 6.12 days for non-operative vs 21.62 days for operative treatment. CONCLUSION: The reported rate of SBO of 3.6% (at 3 years time interval) is in accordance with other studies. With 38% of patients being treated operatively at first admission there is good acceptance for conservative management in non-strangulated SBO. The prolonged hospital stay for patients needing surgery warrants further investigation.     

小肠梗阻的临床诊治进展

既往由于缺乏有效的检查手段,以及对小肠梗阻疾病认识局限,小肠梗阻的临床诊疗比较困难,以致延误了该类疾病的诊治。近年来随着各种影像学技术的飞速发展和对小肠粘连性梗阻的深入研究,使小肠梗阻疾病的诊疗水平有了很大的提高。本文就小肠梗阻的诊治现状做一回顾。     

施他宁在术后早期炎性肠梗阻治疗中的应用

目的探讨施他宁在术后早期炎性肠梗阻中的治疗作用。方法对我院2002年10月至2005年5月期间63例术后早期炎性肠梗阻患者,双盲法应用超过2 d的施他宁治疗,随机分为施他宁 常规治疗组(治疗组,33例)和常规治疗组(对照组,30例),观察临床症状、胃肠减压量、腹部平片、明确肠梗阻后的平均住院时间等各项指标,对结果分别进行对比。结果施他宁组较常规治疗组腹胀均有不同程度的缓解,腹部平片显示液平面明显减少、变小。施他宁组患者的胃肠减压量(525.7±292.5)ml/d较常规治疗组(895.6±351.4)ml/d明显减少,且平均住院时间(13.3±8.5)d较常规治疗组(20.6±11.7)d明显缩短,差异有统计学意义(P<0.05)。结论施他宁能抑制消化道内液分泌、缓解扩张、促进肠蠕动,对治疗术后早期炎性肠梗阻有明显作用。     

外伤性脾脏切除术后早期炎性肠梗阻诊治

目的 探讨外伤性脾脏切除术后早期炎性肠梗阻致病的相关因素、临床表现、治疗方法及并发症的预防.方法 回顾性分析我院2006年1月至2014年1月外伤性脾脏切除术后早期炎性肠梗阻32例病人的临床资料.结果 非手术治疗痊愈30例,随访1～3年,其中1例1年后因粘连性肠梗阻再次手术治疗,术后病人痊愈;手术治疗2例,其中1例术后因肠瘘引起严重感染而死亡,另1例术中行小肠造瘘,半年后再次手术后痊愈.结论 外伤性脾脏切除术后早期炎性肠梗阻的发生与外伤时间、术中肠管暴露时间及有无合并其他脏器损伤有关,治疗以非手术治疗为主,但同时要与机械性肠梗阻相鉴别,以避免不必要的再次手术带来的严重并发症.     

Laparoscopic adhesiolysis in acute small bowel obstruction: a preliminary experience.

OBJECTIVE: The aim of this study is to evaluate laparoscopy as another tool for management of cases of adhesive acute small bowel obstruction. METHODS: Fourteen patients suffering from suspected adhesive small bowel obstruction were explored laparoscopically over a period of 24 months. The Veress needle was inserted either in a virgin part of the abdomen away from previous scars or under direct vision using an open technique. Careful inspection of the entire abdomen was done, and the small bowel was "run" in a retrograde fashion starting at the cecum. The point of obstruction was localized and adhesiolysis was performed, thus resolving the problem. RESULTS: Laparoscopic exploration was able to determine the site and cause of obstruction precisely in all 14 cases, with resolution of the problem laparoscopically in 12 patients (85.7%). Two cases were converted to open surgery (14.3%). There were no mortalities and low morbidity (7.1%). The mean hospital stay was 3.7 days. CONCLUSION: Laparoscopic surgery can be an advantageous alternative to open surgery in acute small bowel obstruction, thus providing a new technique for its diagnosis and treatment with all the advantages of minimally invasive surgery.     

术后早期炎性肠梗阻的诊断与治疗

目的 探讨术后早期炎性肠梗阻的特点和诊断、治疗原则。方法 分析近期内经治的术后早期肠梗阻５例。结果 ５例病人均经胃肠减压,应用生长抑素、肾上腺皮质激素等治愈,平均治愈时间为１３天,无一例肠坏死。结论 术后早期肠梗阻的时间概念最好定在１个月以内。术后早期炎性肠梗阻的特点有：（１）发生在手术后早期,常于术后３～７天左右开始出现梗阻症状;（２）症状以腹胀为主,腹痛相对较轻;（３）肠梗阻症状、体征十分典型     

Therapeutic value of sesame oil in the treatment of adhesive small bowel obstruction

Background

The optimal treatment of partial adhesive small bowel obstruction (SBO) is still controversial. The purpose of this study was to determine the effects of oral administration of sesame oil to the standard of conservative treatment in this disease.

Methods

Sixty-four cases of partial adhesive SBO were retrospectively allocated into either the control group or the intervention group (with sesame oil added), and clinical results were compared.

Results

Of the 64 patients, 33 were in the control group and 31 in the intervention group. Significantly fewer patients required surgical intervention in the intervention group than in the control group (4/31 vs 16/33, P = .0029). Less SBO resolution time (24 hour vs 30 hour, P = .0019) and a shorter hospital stay (6 days vs 10 days, P = .0235) were observed in the interventional group.

Conclusions

Our study showed that sesame oil was a safe and effective adjunct to the standard treatment of partial adhesive SBO.     

Implementation of an adhesive small bowel obstruction protocol using low-osmolar water soluble contrast and the impact on patient outcomes

Background

Small bowel obstruction (SBO) is a common condition leading to numerous hospital admissions and operations. Standardized care of adhesive SBO patients has not been widely implemented in hospital systems.

Water-soluble contrast agent in adhesive small bowel obstruction: a systematic review and meta-analysis of diagnostic and therapeutic value

Background

Adhesive small bowel obstructions are the most common postoperative causes of hospitalization. Several studies investigated the diagnostic and therapeutic role of water-soluble contrast agent (WSCA) in predicting the need for surgery, but there is no consensus.

Methods

A systematic review and meta-analysis was done of studies on diagnostic and therapeutic role of oral WSCA.

Results

WSCA had a sensitivity of 92% and a specificity of 93% in predicting resolution of obstruction without surgery; diagnostic accuracy increased significantly if abdominal X-rays were taken after 8 hours. The administration of oral WSCA reduced the need for surgery (odds ratio .55, P = .003), length of stay (weighted mean difference −2.18 days, P < .00001), and time to resolution (weighted mean difference −28.25 hours, P < .00001). No differences in terms of morbidity or mortality were recorded.

Conclusions

The administration of WSCA is accurate in predicting the need for surgery; the test should be taken after at least 8 hours from administration. WSCA is a proven safe and effective treatment, correlated with a significant reduction in the need for surgery and in the length of hospital stay.     

术后早期炎性肠梗阻的多方位集束治疗

目的 探讨多方位集束治疗策略在术后早期炎性肠梗阻的临床应用.方法 回顾性分析吉林大学第一医院胃结直肠外科2007年7月至2011年7月间收治的31例术后早期炎性肠梗阻患者的临床资料.其中采用多方位集束治疗者13 例（治疗组）,采用其他非手术方法治疗者18例（对照组）,比较两组患者的治疗效果.结果 治疗组和对照组患者治疗后4d好转率分别为76.9％（10/13）和44.4％（8/18）,7d治愈率分别92.3％（12/13）和77.8％ （14/18）,差异均有统计学意义（均P＜0.05）.治疗组比对照组治疗后肠鸣音恢复时间[（2.3±1.5）d比（4.7±1.9）d]、肛门排气时间[（2.9±2.4）d比（5.1±3.7）d]、排粪时间[（3.5±2.7）d比（6.2±2.8）d]、腹胀消失时间[（4.6±2.3）d比 （9.1±3.4）d]、开始经口进食时间[（5.9±1.8）d比（10.2±2.7）d]、腹部CT肠管改善时间[（6.6±3.5）d比 （11.4±9.6）d]以及从治疗开始至出院时间[（7.3±2.9）d比（14.8±11.2）d]均缩短,差异均有统计学意义（P＜0.05）.结论 多方位集束治疗策略可有效缩短术后早期炎性肠梗阻治愈时间,具有良好的应用前景.     

尼古丁对腹部术后早期炎性肠梗阻的治疗作用

目的 探讨尼古丁对腹部术后早期炎性肠梗阻的治疗作用.方法 将45例术后早期炎性肠梗阻的病人随机分为两组,对照组(26例)给予常规保守治疗加无尼古丁贴片;研究组(19例)在常规治疗基础上给予尼古丁贴片(21 mg/片),每日更换一次贴片,应用至治愈或最长至7d.结果 研究组与对照组在腹痛缓解时间[(4.3±1.2)d与(5.3±1.4)d]、腹胀缓解时间[(3.7±1.5)d与(4.9±2.2)d]、肠鸣音恢复时间[(3.2±1.3)d与(4.4±1.7)d]、肛门排气时间[(4.5±1.2)d与(6.2±1.8)d]、治疗至出院时间[(7.3±2.6)d与(9.5±3.7)d]等方面相比均较短且差异有统计学意义(P＜0.05);研究组与对照组的治愈率、总有效率相比,差异无统计学意义(P＞0.05).结论 尼古丁用于腹部术后早期炎性肠梗阻的治疗中可促进症状缓解、加快梗阻解除,缩短疗程,但对于治愈率未有显著提高.