General Surgery Residency and Emergency General Surgery Service Reduces Readmission Rates and Length of Stay in Nonoperative Small Bowel Obstruction

Background Nonoperative management of adhesive small bowel obstruction (ASBO) results in resolution for the majority of patients. Previous studies have demonstrated that outcomes for patients with ASBO are improved when patients are admitted to a surgical service, but the effect of general surgery resident coverage is unclear. This study measures quality outcomes for patients with ASBO after the establishment of a new general surgery residency program. Methods An institutional review board-approved retrospective chart review of admissions for ASBO was conducted following the implementation of a protocol for ASBO nested within a newly developed resident-run emergency general surgery (EGS) service. Patients successfully treated without operative intervention were analyzed. Results During the study period, 612 patients were admitted for ASBO. After initiation of the residency, 74% of ASBO were admitted to a surgical service compared with 35% prior to residency ( P < .01). Length of stay was reduced by 0.77 days ( P = .016), average direct total cost per patient was reduced by 24% ( P = .002), and 30-day readmissions were reduced by 35.7% ( P = .046). There was no significant difference in mortality (1.4% vs 1.0%). Discussion Admission to a resident-run surgical service was associated with statistically significant improvement in outcomes for patients with ASBO. These data corroborate prior studies demonstrating the positive impact of residency programs on patient outcomes and provide additional evidence that general surgery residency programs improve outcomes for patients with surgical disease.

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Hand-Sewn versus Stapled Closure of Loop Ileostomy: A Meta-Analysis

Digestive Surgery ◽

10.1159/000487310 ◽

2018 ◽

Vol 36 (3) ◽

pp. 183-194 ◽

Cited By ~ 8

Author(s):

Rana Madani ◽

Nigel Day ◽

Lalit Kumar ◽

Henry S. Tilney ◽

Andrew Mark Gudgeon

Keyword(s):

Small Bowel ◽

Small Bowel Obstruction ◽

Anastomotic Leak ◽

Bowel Obstruction ◽

Group Performance ◽

Bowel Resection ◽

Loop Ileostomy ◽

Complication Rates ◽

Definitive Answer ◽

Significant Difference

Background: Individual trials comparing hand-sewn with stapled closure of loop ileostomy show different outcomes due to lack of statistical power. A systematic review, with a pooled analysis of results, might provide a more definitive answer. This review aimed to compare hand-sewn with stapled anastomotic technique for closure of a loop ileostomy and looked at the effect of bowel resection on the complication rates. Methodology: Relevant studies were identified from MEDLINE, EMBASE and the Cochrane database. All randomised clinical trials, prospective and retrospective studies comparing hand-sewn with stapled closure of loop ileostomy were included. Results: Of the 4,917 patients in 15 identified studies, 3,406 had hand-sewn and 1,511 stapled anastomosis. There was no difference in the rate of anastomotic leak between the hand-sewn (2.93%, 55/1,877) and the stapled group (2.08%, 25/1,202) (OR 0.81, 95% CI 0.43–1.54, p = 0.52, I2 = 33%). The rate of small-bowel obstruction was higher in the hand-sewn group (7.03%, 231/3,284) compared to the stapled group (5.58%, 73/1,308; OR 0.69, 95% CI 0.51–0.92, p = 0.01, I2 = 0%). There was no difference in the incidence of anastomotic leak and small-bowel obstruction in the hand-sewn anastomosis between patients with or without bowel resection. Conclusions: There was no significant difference in the rate of anastomotic leakage between the hand-sewn and stapled techniques. The rate of small-bowel obstruction was higher in the hand-sewn group. Performance of bowel resection does not significantly increase the incidence of anastomotic leak or small-bowel obstruction.

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Routine Nasogastric Decompression in Small Bowel Obstruction: Is it Really Necessary?

The American Surgeon ◽

10.1177/000313481307900433 ◽

2013 ◽

Vol 79 (4) ◽

pp. 422-428 ◽

Cited By ~ 9

Author(s):

Annabelle L. Fonseca ◽

Kevin M. Schuster ◽

Adrian A. Maung ◽

Lewis J. Kaplan ◽

Kimberly A. Davis

Keyword(s):

Respiratory Failure ◽

Small Bowel ◽

Length Of Stay ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Retrospective Chart Review ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Increased Risk ◽

Nasogastric Decompression

Bowel rest, nasogastric (NG) decompression, and intravenous hydration are used to treat small bowel obstruction (SBO) conservatively; however, there are no data to support nasogastric tube (NGT) use in patients without active emesis. We aim to evaluate the use of nasogastric decompression in SBO and the safety of managing patients with SBO without the use of a NGT. A retrospective chart review was conducted of adult patients admitted to Yale New Haven Hospital over five years with the diagnosis of SBO. We compared patients who received NG decompression with those who did not. Outcome variables assessed were days to resolution, associated complications, hospital length of stay, and disposition. Of 290 patients who fit the criteria, 190 patients (65.52%) were managed conservatively. Fifty-five patients (18.97%) did not receive NGTs. Sixty-eight patients (23.45%) did not present with emesis; however, nearly 75 per cent of these patients received NGTs. Development of pneumonia and respiratory failure was significantly associated with NGT placement. Time to resolution and hospital length of stay were significantly higher in patients with NGTs. Patients with NG decompression had a significantly increased risk of pneumonia and respiratory failure as well as increased time to resolution and hospital length of stay.

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Young Investigator: Corticosteroid Use Is Not Associated With Decreased Length of Stay in Patients Hospitalized With Crohnʼs Associated Small Bowel Obstruction

The American Journal of Gastroenterology ◽

10.14309/00000434-201802001-00097 ◽

2018 ◽

Vol 113 ◽

pp. S22-S23

Author(s):

Quarta Giulio ◽

Thanawala Shivani ◽

Liu Yingheng ◽

Chang Shannon ◽

Malter Lisa ◽

...

Keyword(s):

Small Bowel ◽

Length Of Stay ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Young Investigator

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Clinical Analysis of the Curative Effect of a Transnasal Ileus Tube in the Treatment of Small Bowel Obstruction Caused by a Phytobezoar

Gastroenterology Research and Practice ◽

10.1155/2020/4295024 ◽

2020 ◽

Vol 2020 ◽

pp. 1-8

Author(s):

Yong-Xu Lin ◽

Sun-Jian Wang ◽

Hui-Shun Liang ◽

Su Lin ◽

Li-Yong Bian ◽

...

Keyword(s):

Small Bowel ◽

Conservative Treatment ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Albumin Level ◽

Tube Placement ◽

Curative Effect ◽

Duration Of Symptoms ◽

Conservative Group ◽

Significant Difference

Objective. To investigate the curative effect of a transnasal ileus tube in the treatment of small bowel obstruction caused by a phytobezoar. Methods. Seventy-one patients with small bowel obstruction caused by a phytobezoar who underwent treatment in three provincial tertiary grade A hospitals in Fujian Province from March 2011 to February 2020 were included in this study. Patients were divided into the following two groups according to the treatment received: (1) conservative group, comprising patients who received medical conservative treatment, and (2) combined group, including patients who received combined medical conservative treatment and transnasal ileus tube placement. The clinical symptoms, changes in abdominal imaging, tube depth of the first day, reduction of pressure volume on the first day after catheterization, length of hospital stay, and nonsurgical rate were compared between the combined and conservative groups. Results. There was no significant difference in age, sex, history of previous abdominal surgery and abdominal radiotherapy, symptoms at admission, duration of symptoms before admission, signs at admission, laboratory data, and obstruction position between the combined and conservative groups. There was a statistically significant difference in the nonsurgical rate (19/24 vs. 23/47, P = 0.014 ) between the combined and conservative groups. Logistic analysis showed that the duration of symptoms before admission, albumin level, and use of a transnasal ileus tube might be independent factors affecting the transition to surgery for patients with small bowel obstruction caused by a phytobezoar ( P < 0.05 ). Conclusion. Timely conservative medical treatment with transnasal ileus tube placement can effectively improve the nonsurgical rate of small bowel obstruction caused by a phytobezoar. The duration of symptoms before admission, albumin level, and use of a transnasal ileus tube were closely related to whether patients with small bowel obstruction caused by phytobezoar were transferred to surgery.

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Water-Soluble Contrast Media in Radiography of Small Bowel Obstruction

Acta Radiologica ◽

10.1177/028418518802900111 ◽

1988 ◽

Vol 29 (1) ◽

pp. 53-56 ◽

Cited By ~ 40

Author(s):

A. Stordahl ◽

F. Laerum ◽

T. Gjølberg ◽

I. Enge

Keyword(s):

Small Bowel ◽

Contrast Media ◽

Contrast Medium ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Water Soluble ◽

Double Blind ◽

Peritoneal Adhesions ◽

Significant Difference ◽

Better Than

Fifty patients with possible gastrointestinal obstruction, referred for enteric follow-through examination, were randomized for a double-blind, parallel comparison of the hyperosmolar contrast medium Gastrografin and the low-osmolar Omnipaque. The result was that Omnipaque retained its radiographic density in the small bowel better than Gastrografin. Omnipaque was thus a better alternative than Gastrografin in follow-through examinations of intestinal obstruction. Also, 23 patients out of 28 with small bowel obstruction due to peritoneal adhesions, had spontaneous relief of symptoms during the observation period following contrast medium ingestion with no significant difference between the two media. This indicated that enteric follow-through procedures may have a therapeutic efficacy similar to the treatment of small bowel obstruction using nasogastric suction and gastrointestinal rest. Possible mechanisms for this action of the contrast media are discussed.

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Comparing Surgical Outcomes Among Patients Admitted for Small Bowel Obstruction on Weekend vs. Weekday

The American Surgeon ◽

10.1177/0003134820956333 ◽

2020 ◽

pp. 000313482095633

Author(s):

Samuel D. Butensky ◽

Shirley Y. Hui ◽

Antonio E. Alfonso ◽

Gene F. Coppa ◽

Gainosuke Sugiyama ◽

...

Keyword(s):

Small Bowel ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Negative Binomial ◽

Univariate Analysis ◽

Adverse Outcomes ◽

Patient Specific ◽

Large Hospital ◽

Hospital Size ◽

Significant Difference

Introduction Surgical intervention is important in reducing morbidity and mortality among patients admitted for small bowel obstruction (SBO). Patient-specific variables such as age and comorbidities are risk factors for adverse outcomes after surgery for SBO. However, the effect of weekend admission on outcomes has not been well delineated in the literature. Our aim was to determine whether weekend admission affects mortality and length of stay (LOS) in patients who were admitted for SBO and were managed operatively. Materials and Methods Using the 2006-2012 Nationwide Inpatient Sample (NIS) database, we identified adult patients who were admitted with a primary diagnosis of SBO and had a primary procedure of exploratory laparotomy, lysis of adhesions, or small bowel resection. We performed univariate analysis comparing cases that were admitted on the weekend vs. weekday. We then performed negative binomial regression with LOS as the dependent variable, adjusting for risk variables. Results 2804 patients were studied, of which 728 (26.0%) were admitted on the weekend. Univariate analysis showed no statistically significant difference in mortality or LOS for patients admitted on a weekday vs. weekend. Multivariate analysis showed that several factors were associated with increased LOS, including third quartile van Walraven score ( P < .0001) and large hospital size ( P = .0031). Other factors were associated with decreased LOS, including fourth quartile of income ( P = .0022) and weekend admission ( P = .048). Discussion There is no significant difference in mortality between patients admitted on weekend vs. weekday for SBO, but patients admitted on weekend are more likely to have a decreased LOS.

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National Health Burden of Aspiration Pneumonia on Clinical and Operational Outcomes in Patients With Small Bowel Obstruction Requiring Nasogastric Decompression

The American Surgeon ◽

10.1177/0003134820960049 ◽

2020 ◽

pp. 000313482096004

Author(s):

Amit Mehta ◽

Tracey Martin ◽

Berna Demiralp ◽

Marie Steele-Adjognon ◽

Aishwarya Agarwal ◽

...

Keyword(s):

Small Bowel ◽

Mortality Rate ◽

Length Of Stay ◽

Small Bowel Obstruction ◽

Aspiration Pneumonia ◽

Bowel Obstruction ◽

Hospital Costs ◽

Mortality Rates ◽

Hospital Size ◽

Hospitalization Costs

Background Nasogastric tubes (NGTs) are used for decompression in patients with acute small bowel obstruction (SBO); however, their role remains controversial. There is evidence that NGT use is still associated with high incidence of aspiration pneumonia. The aims of this study were to define the prevalence of aspiration pneumonia in patients with SBO managed with an NGT and estimate the association of aspiration pneumonia with 30-day mortality rates, length of stay (LOS), and hospital costs. Materials and Methods A retrospective cohort study was done using Medicare Inpatient Standard Analytic Files from 2016 to 2018. Patients hospitalized with SBO and managed with NGT were identified using an algorithm of ICD-10-CM codes. The key exposure was aspiration pneumonia. Outcome measures included 30-day mortality rates, LOS, and hospital costs. Results 53 715 patients hospitalized with SBO and managed with an NGT were identified and included in the analysis. We observed a prevalence of aspiration pneumonia of 7.3%. The 30-day mortality rate was 31% for those who developed aspiration pneumonia vs. 10% for those without pneumonia ( P < .001). Those with aspiration pneumonia, on average, were hospitalized 7.0 days longer ( P < .001) and accrued $20,543 greater hospitalization costs ( P < .001) than those without pneumonia. Controlling for hospital size and hospital teaching status, we noted a significant association between aspiration pneumonia and increased mortality ( P < .001), longer length of stay ( P < .001), and higher hospital costs ( P < .001). Discussion Among patients hospitalized for SBO who required an NGT, aspiration pneumonia was associated with a higher mortality rate, longer hospital LOS, and higher total hospital costs.

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NELA.01The Impact of Laparoscopy on Emergency Surgery for Adhesional Small Bowel Obstruction: Prospective Single Centre Cohort Study

British Journal of Surgery ◽

10.1093/bjs/znab310.008 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Alexander Darbyshire ◽

Ina Kostakis ◽

Phil Pucher ◽

Simon Toh ◽

Stuart Mercer

Keyword(s):

Regression Analysis ◽

Cohort Study ◽

Small Bowel ◽

Length Of Stay ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Linear Regression Analysis ◽

Surgical Approaches ◽

Emergency Laparotomy ◽

Single Centre

Abstract Aims Laparoscopic adhesiolysis is being increasingly used to treat adhesional small bowel obstruction (ASBO). However, concerns regarding iatrogenic bowel injury and failure to relieve the obstruction have limited its uptake. This study reports our centre’s experience of adopting laparoscopy as the standard operative approach for ASBO. Methods A single centre prospective cohort study was performed incorporating local data from the National Emergency Laparotomy Audit Database; 01/01/2015-31/12/2019. All patients undergoing surgery for ASBO were included. Patient demographic, operative and in-hospital outcome data were compared between different surgical approaches. Linear regression analysis was performed for length of stay. Results Of 299 cases, 76.3% were started laparoscopically and 52.2% successfully completed. Rates of attempted laparoscopy increased over the 5 year period. Patients treated laparoscopically had lower P-POSSUM-mortality (2.1 vs 5.7%, p = <0.001), shorter post-operative LOS (4.2 vs 11.3 days, p = 0.000) and lower in-hospital mortality (2 vs 7 deaths, p = <0.001). In regression analysis, laparoscopy had the strongest association with post-operative LOS ( 8.51, p = 0.002). Conclusion Laparoscopy is a safe and feasible approach for adhesiolysis in the majority of patients with ASBO. It is now the standard approach in our centre, with 83.3% of cases started laparoscopically in 2019. It is associated with reduced post-operative length of stay with no impact on complications or mortality. This challenges the widely held view that laparoscopy should be for selected, straightforward cases.

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