Outcomes of management of intestinal obstruction at an urban tertiary hospital in sub Saharan Africa: a cross-sectional study

Background Intestinal obstruction (IO) is a common cause of acute abdomen globally, it remains challenging as it increases surgical financial expenditure while also causing major morbidity. Clinically it presents with nausea, vomiting, colicky abdominal pain and cessation of bowel movements or passage flatus and stool. Diagnosis, especially in resource limited settings, can be clinical but is usually confirmed radiologically. We studied the current diagnosis, management and outcomes of IO in Mulago Hospital. Materials and methods This was a prospective study done at all the surgical units of Mulago from January to May 2014 to assess general diagnosis and management of IO. Ethical approval was got in line with Helsinki declaration, we used pretested and validated questionnaires to collect data. Informed consent was got with eligible and consenting/assenting patients that fitted the inclusion criteria of age and presenting with suspected intestinal obstruction. Uni-variate and bi-variate variables analysis was done plus measures of association. Results We enrolled 135 patients, excluded 25 and recruited 110 patient. We had more males than females i.e. 71.8% males and 28.2% females. Colicky abdominal pain, abdominal distension, and vomiting were commonest symptoms, then abdominal distension, increased bowel sounds and abdominal tenderness were the commonest signs. Most patients’ (51%) were diagnosed radiologically with a lesser number clinically diagnosed. “Dilated bowel loops” was the commonest radiological sign. Surgery was the main stay of management at 72.7% while 27.3% were conservatively managed. Postoperatively the bowels opened averagely on the 3rd post-operative day (POD) with return of bowel sounds occurring on 5th POD. Most discharges (73%) occurred by the 7th POD. Unfavourable outcomes were prolonged hospital stay followed by wound sepsis (surgical site infection) and then Mortality. Conclusion This study noted that In Mulago we mostly diagnosed patients radiologically with most surgically managed and which is similar to regional practices. Postoperatively bowel opening happening on third POD with return of bowel sounds on fifth POD. Prolonged hospital stay followed by wound sepsis and then mortality were commonest unfavorable management outcomes.

Sonographic Evaluation of Gastric Residual Volume during Enteral Nutrition in Critically Ill Patients Using a Miniaturized Ultrasound Device

Background: To assess the risk of aspiration, nutrient tolerance, and gastric emptying of patients in ICUs, gastric ultrasound can provide information about the gastric contents. Using established formulas, the gastric residual volume (GRV) can be calculated in a standardized way by measuring the gastric antrum. The purpose of this study was to determine the GRV in a cohort of enterally fed patients using a miniaturized ultrasound device to achieve knowledge about feasibility and the GRV over time during the ICU stay. The findings could contribute to the optimization of enteral nutrition (EN) therapy. Methods: A total of 217 ultrasound examinations with 3 measurements each (651 measurements in total) were performed twice daily (morning and evening) in a longitudinal observational study on 18 patients with EN in the interdisciplinary surgical ICU of Saarland University Medical Center. The measured values of the GRV were analyzed in relation to the clinical course, the nutrition, and other parameters. Results: Measurements could be performed without interrupting the flow of clinical care and without pausing EN. The GRV was significantly larger with sparsely auscultated bowel sounds than with normal and excited bowel sounds (p < 0.01). Furthermore, a significantly larger GRV was present when using a high-caloric/low-protein nutritional product compared to an isocaloric product (p = 0.02). The GRV at the morning and evening measurements showed no circadian rhythm. When comparing the first and last ultrasound examination of each patient, there was a tendency towards an increased GRV (p = 0.07). Conclusion: The GRV measured by miniaturized ultrasound devices can provide important information about ICU patients without restricting treatment procedures in the ICU. Measurements are possible while EN therapy is ongoing. Further studies are needed to establish gastric ultrasound as a management tool in nutrition therapy.

Influencing Factors of Gastrointestinal Function Recovery after Gastrointestinal Malignant Tumor

Gastric cancer is a malignant tumor with a high incidence in the world, and the incidence rate only increases every year. Because of the loss of mental property caused by surgery and postoperative recovery treatment, it has become a difficult problem for many families to solve. Exploring the factors affecting the recovery of gastrointestinal function after surgery to accelerate the recovery has become one of the important research topics of current medical experts and scholars. The purpose of this article is to explore the factors affecting the recovery of gastrointestinal function after gastrointestinal malignancies. In this paper, firstly through experimental investigation, the fasting time and operation method of patients undergoing gastrointestinal malignant tumor surgery are used as variables to conduct a controlled experiment, and the first defecation time, exhaust time, and bowel sound recovery of the experimental subjects after surgery are recorded. Changes in time and other indicators are compared to verify whether they affect the recovery of gastrointestinal function. Experimental data showed that the recovery time of bowel sounds was 29.10 ± 11.09 h in patients with fasting time less than or equal to 2 days after operation, the time of first exhaustion was 28.75 ± 27.80 h, and the time of first defecation was 54.70 ± 39.40 h. The recovery time of bowel sounds in patients with fasting time longer than 2 days was 40.47 ± 9.40 h, the first exhaust time was 71.40 ± 17.54 h, and the first defecation time was 98.30 ± 28.16 h. Therefore, resuming diet as soon as possible after operation is beneficial to the recovery of gastrointestinal function in patients with gastrointestinal malignancies.

Prediction and Management of Strangulated Bowel Obstruction: A Multiomics Model Analysis

BackgroundDistinguishing strangulated bowel obstruction (StBO) from simple bowel obstruction (SiBO) still poses a challenge for emergency surgeons. We aimed to construct a predictive model that could distinctly discriminate StBO from SiBO based on the degree of bowel ischemia.MethodsA total of 281 patients diagnosed with intestinal obstruction were enrolled. According to pathological confirmation, patients were divided into a simple bowel obstruction (SiBO, n=236) group and a strangulated bowel obstruction (StBO, n=45) group. The clinical characteristics, laboratory tests and radiomics were compared between the groups via univariate analysis. Binary logistic regression was applied to identify independent risk factors, and then predictive models based on radiomics and multiomics models were constructed. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) were calculated to assess the accuracy of the predicted models. Finally, via stratification analysis, we validated the multiomics model in the prediction of transmural necrosis. ResultsOf the 281 patients with SBO, 45 (16.0%) were found to have StBO, while 236(84.0%) with SiBO. Via univariate analysis, clinical characteristics including pain duration (p=0.036), abdominal pain(p=0.018), tenderness (p=0.020), rebound tenderness (p<0.001), bowel sounds (p=0.014), and laboratory parameters like white blood cell (WBC) (p=0.029), neutrophil (NE)% (p=0.007), low levels of sodium (p=0.009), abnormal potassium (p=0.003), high levels of blood urea nitrogen (BUN) (p<0.001) and glucose (p=0.002), as well as the radiomics consisting of mesenteric fluid (p=0.018), ascites (p=0.002), bowel spiral signs (p<0.001) and edema of bowel wall (p=0.037) were closely related to bowel ischemia. The ascites (OR=4.067) and bowel spiral signs (OR=5.506) were identified as independent risk factors of StBO in the radiomics model, the AUC for which was 0.706 (95%CI, 0.617–0.795). In the multivariate analysis, seven risk factors including pain duration≤3days (OR=3.775), rebound tenderness (OR=5.201), low-to-absent bowel sounds (OR=5.006), low levels of potassium (OR=3.696) and sodium (OR=3.753), high levels of BUN (OR=4.349), high radiomics score (OR=11.264) were identified. The area under the receiver operating characteristics (ROC) curve of the model was 0.857(95%CI, 0.793-0.920). The score of the mutiomics model can be calculated as following formula (1.328*Pd+1.649*Rt+1.611*Bs+1.307*K+1.323*Na+1.470*BUN+2.422*Rad-6.009). In the stratification of risk scores, the proportion of patients with transmural necrosis was significantly greater in the high-risk group (24%) than in the medium-risk group (3%). No transmural necrosis was found in the low-risk group.ConclusionThe novel multiomics model consisting of risk factors for pain duration, rebound tenderness, bowel sounds, potassium, sodium, and BUN levels and radiomics offers a useful tool for predicting StBO. Clinical management can be performed according to the multiomics score; for patients with low risk (scores≤ -3.91), conservative treatment is recommended. For the high-risk group (risk scores> -1.472), there was a strong suggestion for detection with laparotomy. For the remaining patients (-3.091< risk scores ≤ -1.472), dynamic observation is suggested.

Effect of Pre-operative Nutritional Protocol Implementation on Postoperative Outcomes Following Gastrointestinal Surgeries: A Randomized Clinical Trial

Introduction: A significant proportion of patients undergoing major gastrointestinal operations suffer from malnutrition. Although the benefit of postoperative nutritional support is well established, the effects of energy intake during pre-operative period is less reported. The present study was designed to test the effect of structured pre-operative nutritional therapy on the postoperative recovery of patients undergoing major gastrointestinal operations. Methods: A randomized clinical trial was conducted among 80 patients of the surgical gastroenterology department of a tertiary care center in south India. A simple random sampling method was used. The nutritional status of all participants was assessed by subjective global assessment (SGA). While control group received standard energy intake nutrition, the experimental group received calculated nutrition with an extra 50 g of soy protein for seven days pre operatively. Data were analysed using SPSS version 20. Results: The median day of removal of abdominal drainage tube was 3 (0-5) compared to 5 (2.5-7.5) in the control group. In the intervention group, the median time for the appearance of bowel sounds and starting of enteral feeding was 1.1 (0.5) days and 2 (1-2) days, while in the control group, it was 1.6 (0.9) days, 3 (1-4) days, respectively which was significant at P<0.05. Similarly, the mean (SD) postoperative serum albumin on third day was 3.6 (0.4) g/dL vs 3.4 (0.4) g/dL experimental and in the control group. Conclusion: Preoperative nutrition protocol improved the patients’ clinical outcomes in terms of post-operative serum albumin, the timing of bowel sounds, and early initiation of enteral feeds.

Design and development of electronic stethoscope for auscultation

Background: Currently, several companies offer Bluetooth-based electronic stethoscopes. However, the stethoscopes are pretty overpriced. In this case, we need a stethoscope innovation with a more affordable price that carries the same function and improves ear sensitivity during auscultation of heart and lung sounds.Technic: This stethoscope is equipped with a condenser mic that functions as a sound catcher on the stethoscope membrane. The analog data of the condenser mic is regulated by the potential of the pre-amp mic amplifier; then, analog data is forwarded using Bluetooth 5.0 A2DP BT600 USB Wireless Audio Transmitter and received by Bluetooth receiver using earphones.Conclusion: A electronic stethoscope has been successfully developed, which can function adequately to detect, increase heart, lung, bowel sounds, and prenatal sounds.

928 Current Practice in The Investigation and Management of Post-Operative Ileus

Introduction Post-operative ileus is non-obstructive impairment of gastrointestinal motility after surgery. Treatment involves nil-by-mouth, correction of electrolytes and stopping aggravating medications. There is no current national/trust guideline for investigation and management of post-operative ileus. Aim To assess current practice in investigation and management of post-operative ileus on surgical wards at St Thomas’s Hospital. Method All patients with a diagnosis of post-operative ileus on surgical wards between November - December 2020 were identified. Their clinical notes were reviewed, and common themes explored. Results 16 patients were diagnosed with post-operative ileus. 12 (75%) patients were male, with a median age of 60 (IQR: 28). 10 (63%) were open procedures, majority being colorectal (10; 63%), cardiothoracic (3; 19%), urological (2; 13%), vascular (1; 6%) operations. Average time between operation and diagnosis was 5.2 (range: 2-14) days. Bowel sounds were auscultated in only 2 (12.5%) patients at initial assessment. 8 (50%) patients had imaging to confirm diagnosis (AXR; 5, CT scan; 4). Majority (15; 94%) of patients had serum magnesium and potassium checked at diagnosis. All patients with serum potassium &lt;4.0mmol/L (5) and magnesium &lt;0.7mmol/L (2) had intravenous supplementation. 14 (88%) were administered Hartmann’s solution. 10 (63%) patients were made nil-by-mouth and 15 (94%) had a Ryles tube inserted. 2 (12.5%) patients were prescribed a prokinetic, and only 2 had either opioids or laxatives stopped. No patients were offered gum. Conclusions There is apparent clinical variation in investigation and management of post-operative ileus. We plan to develop an evidence-based trust guideline to reduce unwarranted clinical variation.

A prospective study of outcome of resection anastomosis in elective GI surgeries.

Background: Bowel anastomosis is successful when there is accurate union with no tension.Previous literature has compared between hand suturing and stapling devices in retrospective andprospective designs with varying outcomes. In this study a comparison between hand suturing andsurgical stapling in patients undergoing bowel surgery is done. Methods: A prospective study designover a period of 12 months was conducted in 40 patients undergoing elective resection andanastomosis. Different time parameters for anastomisis procedure, time taken for bowel sounds toreturn, resumption of oral feeds, postoperative hospital stay were collected. Follow up for 30 dayspost-operative was done. Results: In total forty patients were studied out of which twenty patientsunderwent hand sewn and twenty patients underwent stapler anastomosis. Main group analysis inmean time durations between hand sewn and stapler anastomosis were respectively; 35.25 minutesand 12 minutes for anastomosis, 3.4 days and 3.35 days for return of bowel sounds, 4.08 days and4 days for resumotion of oral feeds, 9.35 days and 8.50 days for post-operative hospital stay. A sub-group analysis was also done.Conclusion: Stapler anastomosis had shorter anastomosis time andtotal duration of operation compared to hand sewn anastomosis. However no difference was seen inreturn of bowel activity, resumption of oral feeds and duration of hospital stay.