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.

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).

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     

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。     

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.     

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。     

经鼻肠减压管选择性小肠造影诊断肠梗阻

目的 探讨经鼻肠减压管选择性小肠造影对小肠梗阻诊断的临床意义.方法 对35例临床诊断为小肠梗阻并排除急诊手术指征患者,在X线监视下经鼻置入300 cm长的减压管至空肠上段抽吸减压治疗,随着小肠减压的不断深入,减压管前端可以最大限度地接近病变部位进行选择性小肠造影.在透视下经减压管吸引口注入76%泛影葡胺20～100ml,再注入空气50～200ml,使造影剂和空气直接涌入梗阻病灶周围形成双对比造影.对局部进行动态多体位观察,摄取点片.必要时同抽减压管至空肠上段行全小肠双对比造影.结果 本组35例置管全部成功,小肠减压治疗后肠梗阻缓解20例,减轻15例,手术治疗10例.35例选择性小肠造影局部小肠显影清晰,不重叠,重点突出.未见明显异常X线征象6例,粘连性肠梗阻15例,小肠肿瘤4例(转移瘤3例,小肠癌1例),小肠克罗恩病3例,小肠放射性肠炎3例(其中1例造影误诊为小肠转移瘤),小肠套叠2例,小肠息肉1例,升结肠癌1例. 结论鼻肠减压管具有小肠减压治疗与选择性小肠造影检查的双重作用.选择性小肠造影可以明确梗阻部位、梗阻程度和梗阻病因,做出影像学定位与定性诊断,为确定手术时机和手术方案提供可靠依据.     

Development of a simple model for predicting need for surgery in patients who initially undergo conservative management for adhesive small bowel obstruction

Background

Among patients with adhesive small bowel obstruction (ASBO) initially managed with a conservative strategy, predicting risk of operation is difficult.

Methods

We investigated ASBO patients at 2 different periods to derive and validate a clinical prediction model for risk of operation.

Results

One hundred fifty-four patients were enrolled into the derivation cohort and 96 into the validation cohort. Based on the derived scoring, including age ≥65 years, presence of ascites, and gastrointestinal drainage volume >500 mL on day 3, each patient was classified into 1 of 4 risk classes from low risk to high risk. When applied to the validation cohort, the positive predictive value (PPV) for operation in the high-risk class was 72%, while the negative predictive value (NPV) in the low-risk class was 100% with high sensitivity (100%) and specificity (96%).

Conclusions

The prediction model performs well for risk stratification of need for surgical intervention following conservative strategy among ASBO patients.     

腹部手术后早期炎性肠梗阻的治疗

目的 探讨术后早期炎性肠梗阻的特点及治疗原则。方法 回顾性分析近期经治的术后早期炎性肠梗阻 9例。结果 1例患者经手术治疗,分离粘连时引起多发性肠破裂、肠瘘,后经保守治疗治愈; 8例患者均经胃肠减压、抗炎、应用生长抑素等保守治疗治愈,平均治愈时间为 21. 5 d,无 1例肠坏死。结论 术后早期炎性肠梗阻的特点： (1)发生于腹部手术后早期,虽有机械性因素,但大多都是腹腔内炎症所致广泛粘连引起; (2)症状以腹胀为主,腹痛相对轻,部分患者有少量肛门排气排便,体征虽典型,但较少发生绞窄; (3)保守治疗大都有效,治疗上最好先予以生长抑素为主的保守治疗,应严密观察,如出现肠坏死、腹膜炎征象时则再及时中转手术。     

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目的 探讨术后早期炎性肠梗阻的临床特点及处理方法。方法 分析８１例术后早期炎性肠梗阻的临床特点及治疗结果。结果 ８１例均经胃肠减压,应用生长抑素,肠外营养等支持疗法,平均治愈时间为１４．５ｄ,无一例再手术。结论 术后早期炎性肠梗阻多发生在术生５￣７ｄ,可表现为典型的肠梗阻体征,多由小肠无菌性炎症致广泛肠粘连引起,多数病例采用保守疗法可治愈。     

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.     

术后早期炎性肠梗阻诊治体会（附17例报告）

目的　探讨术后早期炎性肠梗阻的临床特点及处理方法。方法　回顾性分析 1 7例术后早期炎性肠梗阻的临床特点及治疗结果。结果　保守治疗 1 4例 ,平均治愈时间 1 0d ;再次手术 3例。结论　术后早期炎性肠梗阻有其临床表现特点 ,多数病例采用保守疗法可治愈。     

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.     

术后早期炎性肠梗阻的特点与诊断治疗原则

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：回顾经治的7例术后早期炎性肠梗阻,21－59岁,术后4－9天发生肠梗阻,结合献进行分析探讨。结果：先经保守治疗,包括胃肠减压,完全胃肠外营养,应用生长激素,生长抑素和肾上腺皮质激素等。3例肠梗阻症状解除,例需经手术治疗,术后症状缓解,其中1例发生肠瘘。结论：术后早期炎性肠梗阻多发生在术后2周内,临床症状以呕吐,腹胀为主,腹痛相对较轻,发病原因包括机械性梗阻因素和肠动力障碍性因素,很少发生绞窄,治疗宜先行保守治疗,无效后考虑手术治疗。     

腹腔镜诊断和治疗小肠不全梗阻的临床研究

目的探讨腹腔镜诊断和治疗小肠不全梗阻的可行性、有效性及安全性。方法回顾性分析我院2003年2月-2007年6月因小肠梗阻接受腹腔镜治疗53例的临床资料。结果本组53例中,完成腹腔镜肠粘连分解术33例;行腹腔镜肠粘连分解术及相应肠道手术18例,其中,纯腹腔镜手术11例,腹腔镜下切口定位并开放手术7例。中转开腹手术2例。腹腔镜探查诊断率达98．11％。术后有8例发生不同类型的并发症。结论腹腔镜诊断和治疗小肠不全梗阻是安全、可行的,可以选择性应用于部分小肠不全梗阻病例。     

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.