Impact of Operative Management on Recurrence of Adhesive Small Bowel Obstruction: A Longitudinal Analysis of a Statewide Database

Medvecz, Andrew J.; Dennis, Bradley M.; Wang, Li; Lindsell, Christopher J.; Guillamondegui, Oscar D.

doi:10.1016/j.jamcollsurg.2019.12.006

Cited by 26 publications

(35 citation statements)

References 25 publications

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“…Another study of 6,191 patients confirmed these outcomes (19% vs 25.6%, p < 0.005). However the authors noted a higher mortality rate in the operative group (3.7% vs 2.6%, p = 0.025) [ 17 ]. The debate is still ongoing and conservative treatment remains the standard of care whenever possible.…”

Section: Discussionmentioning

confidence: 99%

Impact of a procalcitonin-based algorithm on the quality of management of patients with uncomplicated adhesion-related small bowel obstruction assessed by a textbook outcome: a multicenter cluster-randomized open-label controlled trial

et al. 2022

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Background Acute adhesion-related small bowel obstruction (ASBO) is a common digestive emergency, accounting for 1 to 3% of all digestive emergencies. The efficacy of conservative management in this setting is a subject of debate, as it may delay the decision to perform surgery and increase the frequency of bowel resection (e.g., in the presence of bowel necrosis) or, in contrast, prompt an excessive number of unnecessary laparotomies. Thus, the decision to perform surgery is difficult. We propose that the introduction of the procalcitonin (PCT)-based algorithm improves the quality of the management of patients with ASBO by aiding the decision of whether or not to perform surgery. Methods This is a 1:1 cluster-randomized clinical trial (use of algorithm: no algorithm) using an independent computer to ensure that investigators cannot interfere with the randomization. Each cluster will correspond to one investigating center. All patients in a center will be managed in the same way. Before randomization, each principal investigator will provide a commitment to participate in the study to avoid the risk of “empty clusters”. The patients included will constitute two parallel arms (use of algorithm versus no algorithm), with no expected crossover between arms. The inclusion criteria are being an adult with uncomplicated acute ASBO (i.e., absence of fever, abdominal pain and distension, nausea and/or vomiting, and the absence of gas and/or stool, in conjunction with a contrast-enhanced CT scan, for patients with previous abdominal surgery) who is able to express consent with a signed written informed consent form. Patients with complicated acute ASBO (strangulation or peritonitis) will be excluded. Discussion There is an ongoing debate on the management of uncomplicated ASBO. The main points are to avoid a surgery if it is unnecessary and to avoid delayed surgery if it is necessary. Currently, there are no robust criteria to objectively determine the failure of non-surgical treatment or to establish the indications for surgery in acute ASBO. Our team proposes the use of procalcitonin (PCT) to help distinguish patients for whom conservative management is likely to be successful from those for whom surgical management is required. The results from a randomized control trial could help in the selection of patients through clear inclusion and exclusion criteria and simplify or clarify the management algorithm. In conclusion, PCT may be useful in evaluating the proper strategy for ASBO. Trial registration The trial is registered at clinical trials under the reference: NCT03905239

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Section: Discussionmentioning

confidence: 99%

Impact of a procalcitonin-based algorithm on the quality of management of patients with uncomplicated adhesion-related small bowel obstruction assessed by a textbook outcome: a multicenter cluster-randomized open-label controlled trial

et al. 2022

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“…This may be due to the careful observation and switching to LT even when colonic contrast was observed at 24 h. ASBO recurrence frequently occurs due to the inability of non-surgical treatment to resolve itself. [7][8][9] Despite being able to temporally reduce ASBO recurrence, surgical treatment is more invasive, especially for elderly patients with severe risk factors. 8 In addition, surgery may cause subsequent adhesive stenosis.…”

Section: Discussionmentioning

confidence: 99%

“…[7][8][9] Despite being able to temporally reduce ASBO recurrence, surgical treatment is more invasive, especially for elderly patients with severe risk factors. 8 In addition, surgery may cause subsequent adhesive stenosis. Thus, non-surgical management should be recommended as an initial treatment for patients with ASBO, unless signs of peritonitis, strangulation, or bowel ischemia become apparent.…”

Section: Discussionmentioning

confidence: 99%

Long‐term outcomes of nasogastric tube with Gastrografin for adhesive small bowel obstruction

Nishie

Shimura

Katano

et al. 2021

J of Gastro and Hepatol

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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.

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“…For this analysis, our model assumed an encounter-level recurrence rate of 28.8%, which was inferred from a retrospective statewide study of 6191 patients in Tennessee followed from 2007 to 2016. 35 Our analysis required that the recurrence rate be reported at the encounter level as opposed to the patient level (i.e., percentage of SBO encounters that are recurrent versus percentage of patients who experience a recurrence) given our analysis is built upon the annual number of ED encounters for SBO. The reported recurrence rate of 28.8% from this study was the most conservative encounter-level recurrence rate reported in the literature (range, 28.8%-62.0%), but was chosen given it was derived most recently using the largest sample.…”

Section: Sensitivity and Subset Analysesmentioning

confidence: 99%

Point‐of‐care ultrasound‐first for the evaluation of small bowel obstruction: National cost savings, length of stay reduction, and preventable radiation exposure

Brower

Baugh

Shokoohi

et al. 2022

Academic Emergency Medicine

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Objectives Computed tomography (CT) has long been the gold standard in diagnosing patients with suspected small bowel obstruction (SBO). Recently, point‐of‐care ultrasound (POCUS) has demonstrated comparable test characteristics to CT imaging for the diagnosis of SBO. Our primary objective was to estimate the annual national cost saving impact of a POCUS‐first approach for the evaluation of SBO. Our secondary objectives were to estimate the reduction in radiation exposure and emergency department (ED) length of stay (LOS). Methods We created and ran 1000 trials of a Monte Carlo simulation. The study population included all patients presenting to the ED with abdominal pain who were diagnosed with SBO. Using this simulation, we modeled the national annual cost savings in averted advanced imaging from a POCUS‐first approach for SBO. The model assumes that all patients who require surgery or have non‐diagnostic POCUS exams undergo CT imaging. The model also conservatively assumes that a subset of patients with diagnostic POCUS exams undergo additional confirmatory CT imaging. We used the same Monte Carlo model to estimate the reduction in radiation exposure and total ED bed hours saved. Results A POCUS‐first approach for diagnosing SBO was estimated to save a mean (±SD) of $30.1 million (±8.9 million) by avoiding 143,000 (±31,000) CT scans. This resulted in a national cumulative decrease of 507,000 bed hours (±268,000) in ED LOS. The reduction in radiation exposure to patients could potentially prevent 195 (±56) excess annual cancer cases and 98 (±28) excess annual cancer deaths. Conclusions If adopted widely and used consistently, a POCUS‐first algorithm for SBO could yield substantial national cost savings by averting advanced imaging, decreasing ED LOS, and reducing unnecessary radiation exposure in patients. Clinical decision tools are needed to better identify which patients would most benefit from CT imaging for SBO in the ED.

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Impact of Operative Management on Recurrence of Adhesive Small Bowel Obstruction: A Longitudinal Analysis of a Statewide Database

Cited by 26 publications

References 25 publications

Impact of a procalcitonin-based algorithm on the quality of management of patients with uncomplicated adhesion-related small bowel obstruction assessed by a textbook outcome: a multicenter cluster-randomized open-label controlled trial

Impact of a procalcitonin-based algorithm on the quality of management of patients with uncomplicated adhesion-related small bowel obstruction assessed by a textbook outcome: a multicenter cluster-randomized open-label controlled trial

Long‐term outcomes of nasogastric tube with Gastrografin for adhesive small bowel obstruction

Point‐of‐care ultrasound‐first for the evaluation of small bowel obstruction: National cost savings, length of stay reduction, and preventable radiation exposure

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