Small bowel obstruction in the virgin abdomen: the need for a mandatory laparotomy explored. Beardsley C, Furtado R, Mosse C, Gananadha S, Fergusson J, Jeans P, Beenen E. Am J. Surg. 2014 Aug;208(2):243-8.
Many consider laparotomy mandatory for patients without prior abdominal surgery who present with a small bowel obstruction (SBO). This paper, from a group in Australia, challenges this. This is a retrospective study looking at patients with SBO diagnosed on either plain films or CT scan over a 5-year period. Of 689 patients who presented with SBO, 62 patients (9.0%) had a virgin abdomen. Incarcerated external hernias were excluded. Management was at the discretion of the admitting surgeon. The final diagnosis was based primarily on the operative findings.
Of the 62 patients, a previously-diagnosed underlying disease of malignancy or inflammatory bowel disease was present in 13 patients. Of the other 49 (the population of interest), adhesions were the cause in 37/49 (75.5%) and a newly diagnosed malignancy was the cause in 5/49 (10.2%). Of concern to this reviewer, in 12 patients in whom no pathology was found on CT abdomen or any other investigation, the diagnosis of adhesions was made by exclusion (n=12).
Only in 2 patients was the malignancy unrecognized by the CT scan and diagnosed at the time of laparotomy, and these patients were found to have a jejunal adenocarcinoma (n=1) and a lymphoma (n=1).
The authors conclude that adhesions are by far the most likely cause of SBO in these patients, followed by a small number a newly diagnosed malignancies, and the proportions of these are equal to those with prior abdominal surgery. They feel that mandatory laparotomy is not necessary in this population and that further study is required. Although this is a retrospective study, it is an interesting paper, and further research on this topic is warranted.
The use of magnetic resonance imaging in the diagnosis of suspected appendicitis in pregnancy: shortened length of stay without increase in hospital charges. Fonseca AL, Schuster KM, Kaplan LJ, Maung AA, Lui FY, Davis KA. JAMA Surg. 2014 Jul;149(7):687-93.
The authors begin with a statement that the diagnosis of acute appendicitis in pregnancy is not straightforward. A negative exploration for appendicitis is known to be a positive predictor of fetal loss. In addition, there are concerns about the radiation risk with CT which have led to MR imaging being more commonly used to diagnose appendicitis in pregnancy.
This is a retrospective study over an 11-year period including 79 patients who had an abdominal examination concerning for acute appendicitis. Only 4 patients had CT, and these were excluded. Of the remaining 75 patients, 32 had pathology-confirmed appendicitis. All patients had US, and those with confirmed appendicitis on US underwent surgery; of these patients 13/14 had appendicitis. Those without appendicitis on US underwent clinical observation (n=30) or MR (n=31). Of the 31 patients who underwent MR imaging, eleven had an MR diagnosis of appendicitis, all of whom had a clinical confirmation of appendicitis.
With respect to diagnostic accuracy, clinical diagnosis had a sensitivity of 25% and a specificity of 91%, ultrasonography had a sensitivity of 39% and a specificity of 98%, while MR imaging had a sensitivity of 100% and a specificity of 100%. In the MR group, fewer operations were performed, but this did not reach statistical significance (p=0.07). Seven nontherapeutic operations were performed in the non-MR group and only one in the MR group (done for clinical suspicion in patient with equivocal MR).
Those in the MR group were more frequently discharged from the emergency department, and this group also had a shorter length of stay. Multivariate analysis showed that the absence of operative intervention and the receipt of MR imaging were associated with a shorter LOS.
In conclusion: In pregnant patients with suspected appendicitis, clinical examination was associated with a high negative exploration rate; it was recommended that US be used as the initial imaging examination; those undergoing MR had lower incidences of operative exploration and nontherapeutic exploration; MR imaging was associated with a decrease in hospital admissions and a decrease in length of stay; and MR imaging improved resource use and allowed safe discharge from the emergency department.
Long-term follow-up for adhesive small bowel obstruction after open versus laparoscopic surgery for suspected appendicitis. Isaksson K, Montgomery A, Moberg AC, Andersson R, Tingstedt B. Ann Surg. 2014 Jun;259(6):1173-7.
The aim of this study was to compare the frequency of readmission due to small bowel obstruction (SBO) after open versus laparoscopic surgery performed for acute appendicitis. Adult patients who had surgery in two hospitals in Sweden between 1992 and 2007 were included. The approach was primarily laparoscopic at one hospital and open in the other. The two approaches were compared retrospectively, reviewing charts until the middle of 2012.
There were 2333 patients in the open group and 2372 in the laparoscopic group. In the laparoscopic group, 1401 patients had laparoscopic appendectomy (59%), 595 converted to open appendectomy (25%), and 376 had only diagnostic laparoscopy without appendectomy (16%). The mean follow-up time was 161 months in the open group and 133 months in the laparoscopic group.
The frequency of hospitalization for SBO was low in both groups, but there was a significant difference (1.0% in the open group and 0.4% in the laparoscopic group; p=0.015), favoring the laparoscopic group. About half of SBO in both group were managed surgically. Open appendectomy and older age were independent risk factors for SBO in multivariate analysis.
In the per protocol analysis in with the converted patients in the laparoscopic group were excluded, there was a significant difference in the incidence of readmission for SBO in favor of the laparoscopic group (0.3% vs 1.0%; p=0.009).
Risk of readmission and emergency surgery following nonoperative management of colonic diverticulitis: a population-based analysis. Li D, de Mestral C, Baxter NN, McLeod RS, Moineddin R, Wilton AS, Nathens AB. Ann Surg. Sep;260(3):423-30; discussion 430-1.
The objective of this paper was to characterize the clinical course of patients managed nonoperatively for acute diverticulitis and to provide estimates of the rates of readmission and of emergency surgery, accounting for the competing events of elective operation and all-cause mortality.
This is a retrospective study of patients who were managed nonoperatively (discharged without colectomy) after a first episode of diverticulitis from 4/1/02-3/31/12. The study used a population-based administrative health database from the province of Ontario, and vital statistics were obtained from the Ontario registered persons database.
Patients with a previous ED visit or hospitalization for diverticulitis were excluded, as were those with concurrent GI bleeding or any history of colorectal cancer or of colectomy. Those who were discharged from the hospital without operation and who had at least 30 days of follow-up comprised the final study cohort. The first 30 days after the index admission were censored (felt to be persistent rather than recurrent disease).
There were 14,124 adult patients who were followed for a median of 3.9 years. At 5 years, 9.0% were readmitted and 1.9% had emergency surgery, and there was an all-cause mortality of 14.1%. Patients with complicated disease (abscess or perforation) had a higher rate of readmission and increased risk of emergency surgery compared with those with uncomplicated disease. Of the patients that experienced at least one readmission, the majority (55%) had a readmission within the first year after discharge.
After adjustment for other factors, age less than 50 years and complicated disease at the index admission were associated with an increased risk of readmission, and complicated disease and number of prior admissions were associated with an increased risk of emergency surgery, but an age younger than 50 years was not.
The authors concluded that elective prophylactic colectomy may not be warranted for the majority of patients that have had an episode of diverticulitis managed nonoperatively, lending further support to the practice of deferring elective colectomy unless the patients have persistent symptoms or multiple recurrences.
The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Di Saverio S, Sibilio A, Giorgini E, Biscardi A, Villani S, Coccolini F, Smerieri N, Pisano M, Ansaloni L, Sartelli M, Catena F, Tugnoli G. Ann. Surg. 2014 Jul;260(1):109-17.
The purpose of this study from Bologna, Italy was to assess the safety and efficacy of nonoperative management (NOM) of acute uncomplicated appendicitis. This was a prospective observational study. In the calendar year 2010, 159 adult patients with suspected appendicitis underwent NOM with amoxicillin/clavulanate. The clinical assessment of acute appendicitis was made by an attending general surgeon, conformed by either the Alvarado score or by the Appendicitis Inflammatory Response (AIR) score. These scores are described in the paper.
Patients with Alvarado scores of 5 or more and less than 10 and/or AIR scores of more than 2 and less than 11 were considered eligible. Patients with diffuse peritonitis, antibiotic allergy, previous antibiotic therapy, previous appendectomy, a positive pregnancy test, or inflammatory bowel disease were excluded. The following patients were taken for immediate surgery: those with diffuse peritonitis and/or signs of severe abdominal sepsis and those with CT or US evidence of intraabdominal collection/abscess or free perforation.
Of the 159 patients who were enrolled in the study, 116 patients (73%) were assessed by US and in 27 patients (17%), CT was requested. All 159 patients underwent NOM and received a course of amoxicillin/clavulanate. Reassessment and enrollment for further follow-up were performed 5 days later as an outpatient. Long-term follow-up was done at 7 days, 15 days, 6 months, and at 1 year and 2 years – the last four of these were done by telephone.
Those who needed surgery at 7 day follow-up were termed failures and those who had recurrence of symptoms after this were termed recurrences. The short-term (<7 days) failure rate was 19/159 (11.9%), and all of these patients received surgery. After two years, the overall recurrence rate was 22/159 (13.8%); of these 14/22 (63.6%) were successfully treated with a further cycle of amoxicillin/clavulanate. Therefore in total, 41/159 (25.8%) had either failure or a recurrence, of whom 27 (65.9%) needed surgery. On multivariate analysis, Alvarado and AIR scores were the only independent predictors of NOM failure.
This is an interesting study from Italy advocating NOM of certain patients who were suspected to have acute appendicitis. US was used in most of these patients to assist with diagnosis. Of note, very few patients in this study had CT scan, and it is not clear how the results of this study from Italy might be applied to areas where the use of CT to diagnose appendicitis is high.