Article of interest: Volvulus of the Small Bowel and Colon

Kapadia MR. Volvulus of the Small Bowel and Colon. Clin Colon Rectal Surg. 2017 Feb; 30(1):40-45.

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“Volvulus of the intestines involves twisting around a fixed point. It may occur anywhere along the gastrointestinal tract where there is a long, mobile intestinal segment with a narrow mesenteric attachment. Volvulus leads to luminal obstruction and can compromise intestinal blood flow. For this reason, it tends to be a surgical emergency which requires prompt attention. Failure to recognize the signs and symptoms of intestinal volvulus may lead to bowel ischemia and perforation.”

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Stoma versus stent as a bridge to surgery for obstructive colon cancer

Veld JV, et al. Changes in Management of Left-Sided Obstructive Colon Cancer: National Practice and Guideline Implementation. J Natl Compr Canc Netw. 2019 Dec;17(12):1512-1520.

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Results: A total of 2,587 patients were included (2,013 ER, 345 DS, and 229 SEMS). A trend was observed in reversal of ER (decrease from 86.2% to 69.6%) and SEMS (increase from 1.3% to 7.8%) after 2014, with an ongoing increase in DS (from 5.2% in 2009 to 22.7% in 2016). DS after 2014 was associated with more laparoscopic resections (66.0% vs 35.5%; P<.001) and more 2-stage procedures (41.5% vs 28.6%; P=.01) with fewer permanent stomas (14.7% vs 29.5%; P=.005). Overall, more laparoscopic resections (25.4% vs 13.2%; P<.001) and shorter total hospital stays (14 vs 15 days; P<.001) were observed after 2014. However, similar rates of primary anastomosis (48.7% vs 48.6%; P=.961), 90-day complications (40.4% vs 37.9%; P=.254), and 90-day mortality (6.5% vs 7.0%; P=.635) were observed.

CONCLUSIONS: Guideline revision resulted in a notable change from ER to BTS for LSOCC. This was accompanied by an increased rate of laparoscopic resections, more 2-stage procedures with a decreased permanent stoma rate in patients receiving DS as BTS, and a shorter total hospital stay. However, overall 90-day complication and mortality rates remained relatively high.

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Small bowel obstruction: clinical and radiographic predictors for surgical intervention

One discussion this week included the clinical and radiographic signs for operation or nonoperation in the setting of adhesive small bowel obstruction (ASBO).


Reference: Kulvatunyou N, et al. A multi-institution prospective observational study of small bowel obstruction: Clinical and computerized tomography predictors of which patients may require early surgery. The Journal of Trauma and Acute Care Surgery. 2015. 79(3);393-398. doi:10.1079/TA.0000000000000759.

Summary: The absence of flatus and the CT finding of free fluid and high-grade obstruction have been identified by Kulvatunyou et al (2015) as predictors that early operative intervention would be beneficial. This prospective observational study involved 200 patients at three academic and tertiary referral medical centers; 148 in the nonoperative group, 52 in the operative group.

Clinical signs: The only clinical sign identified as a predictor for surgical intervention, “no flatus” was listed in 58% of the operative group, 34% of the nonoperative group. Too large to include here, Table 3 in the text (p.397) lists the univariate analysis of all clinical signs.

CT findings: Individual CT signs listed include transition point, free fluid, multiple fluid locations, small bowel fecalization, mesenteric edema, closed loop, and high-grad obstruction. All had low PPVs, ranging 21-41%. Using the three predictors identified, the PPV improved but remained low at 37-56% (p.397).

The table below (p.397) illustrates the utility of the three variables in a few combinations.

predictors

In the article, the authors state that they are currently (2015) pursuing a study applying the predictors to a different ASBO patient population so as to cross-validate this predictor model. A search for such a study in the published literature was not successful.

Additional Reading: Catena F, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2010 evidence-based guidelines of the World Society of Emergency Surgery. World Journal of Emergency Surgery. 2011 Jan 21;6:5. doi: 10.1186/1749-7922-6-5.