Should adhesive small bowel obstruction be managed laparoscopically? A National Surgical Quality Improvement Program propensity score analysis.

BACKGROUND: Celiotomy is the most common approach for refractory small bowel obstruction (SBO). Small reviews suggest that a laparoscopic approach is associated with shorter stay and less morbidity. Given the limitations of previous studies, we sought to evaluate outcomes of laparoscopic (L) compared with open (O) adhesiolysis for SBO, using the National Surgical Quality Improvement Program data set. METHODS: Patients from the American College of Surgeons' National Surgical Quality Improvement Program 2005 to 2009 database who underwent surgery for SBO were stratified based on surgical approach. A propensity score to undergo L instead of O was calculated based on demographics, comorbidities, physiology, and laboratory values. Logistic regression was then used to determine differences in outcomes between those propensity score-matched patients who actually underwent L compared with O surgery. RESULTS: There were 6,762 patients who underwent adhesiolysis. The propensity score-matching process created 222 matched patients in L and O groups. Laparoscopy was associated with significantly lower rates of any complication (odds ratio [OR] 0.41; 95% confidence interval [CI], 0.28-0.60), including superficial site infections (OR, 0.15; 95% CI, 0.05-0.49), intraoperative transfusion (OR, 0.22; 95% CI, 0.05-0.90), and shorter hospital stay (4 days vs. 10 days; p < 0.001). There was no significant difference in operative time, rates of reoperation within 30 days, or mortality. CONCLUSION: Laparoscopic treatment of SBO is associated with lower rates of postoperative morbidity compared with laparotomy as well as shorter hospital stay. Laparoscopic treatment of surgical SBO is not associated with higher rates of early reoperation and seems to be associated with lower resource use. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Development of a quantitative method for the diagnosis of cirrhosis.

OBJECTIVE: To develop a novel non-invasive, quantitative approach utilizing computed tomography scans to predict cirrhosis. MATERIALS AND METHODS: A total of 105 patients (54 cirrhosis and 51 normal) who had CT scans within 6 months of a liver biopsy or were identified through a Trauma registry were included in this study. Patients were randomly divided into the training set (n = 81) and the validation set (n = 24). Each liver was segmented in a semi-automated fashion from a computed tomography scan using Mimics software. The resulting liver surfaces were saved as a stereo lithography mesh into an Oracle database, and analyzed in MATLAB(®) for morphological markers of cirrhosis. RESULTS: The best predictive model for diagnosing cirrhosis consisted of liver slice-bounding box slice ratio, the dimensions of the liver bounding box, liver slice area, slice perimeter, surface volume and adjusted surface area. With this model, we calculated an area under the receiver operating characteristic curve of 0.90 for the training set, and 0.91 for the validation set. For comparison, we calculated an area under the receiver operating characteristic curve of 0.70 for our dataset when we used the lab value based aspartate aminotransferase-platelet ratio index, another reported model for predicting cirrhosis. Last, by combining the aspartate aminotransferase-platelet ratio index and our model, we obtained an area under the receiving operating characteristic of 0.95. CONCLUSION: This study shows "proof of concept" that quantitative image analysis of livers on computed tomography scans may be utilized to predict cirrhosis in the absence of a liver biopsy.