Severe small intestinal bacterial overgrowth syndrome after jejunal feeding requiring surgical intervention: a case report and review of the literature.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is a condition of unknown prevalence characterized by an excessive amount of bacteria in the small bowel, typically resulting in vague gastrointestinal symptoms with bloating being most commonly reported. Here we describe a severe case of SIBO leading to small bowel necrosis requiring surgical intervention. CASE PRESENTATION: A 55-year-old Hispanic female with gastric outlet obstruction secondary to a newly diagnosed gastric adenocarcinoma, receiving neoadjuvant chemotherapy, developed bloody gastrostomy output and rapidly progressing nausea and abdominal distention 3 days after jejunostomy tube placement and initiation of jejunal enteral nutrition. Imaging revealed diffuse pneumatosis and portal venous gas. Surgical exploration confirmed segmental bowel necrosis requiring resection. Histologic findings were consistent with SIBO. CONCLUSIONS: Presentation of severe SIBO in the setting of intestinal stasis secondary to gastric outlet after initiation of enteral feeds is a rare phenomenon. Early recognition and diagnosis of SIBO is critical in minimizing patient morbidity and mortality.

Trends of inguinal hernia repairs performed for recurrence in the United States.

BACKGROUND: One of the main complications of inguinal hernia repair continues to be recurrence. Commonly cited prior reports from relatively small studies estimate this rate to be 1% to 5% in the United States. Although some reports have found higher recurrence rates, they get little attention on the national stage or in other large studies. We sought to determine the trend of inguinal hernia repairs performed for recurrence over time using large national databases. METHODS: We identified patients aged ≥18 years who underwent inguinal hernia repair from three sources: the Premier database (January 2010 to September 2015), the American College of Surgeons National Surgical Quality Improvement Program database (January 2005 to December 2014), and the Mayo Clinic institutions (January 2005 to December 2014). We evaluated the incidence of primary and recurrent inguinal hernia repairs stratified by sex over time using one-tailed Cochran-Armitage tests. RESULTS: In the Premier database, of the 317,636 inguinal hernia repairs, the proportion performed for recurrence had a small decrease in males from 11.4% in 2010 to 10.5% in 2015 (P < .0001); however, it remained constant in females (6.5% in 2010 to 6.7% in 2015, P = .46). In the National Surgical Quality Improvement Program database, of the 180,512 inguinal hernia repairs, there was no change for either sex: 10.5% to 11.2% (2005-2014, P = .12) in males and 6.2% to 7.1% (2005-2014, P = .11) in females. Within our institution, in the 9,216 patients identified, there was no change in the proportion of inguinal hernia repairs for recurrence in males: 13.3% to 11.5% (2005-2014, P = .25). In females, the proportion increased from 1.3% to 12.0% during the study period (P = .006). CONCLUSION: Based on these larger evaluations of recurrent inguinal hernia surgery, the current literature on inguinal hernia repair recurrence is skewed and overly optimistic.

Functional gallbladder disease: Operative trends and short-term outcomes.

BACKGROUND: Due to increasing rates of functional gallbladder disease (FGBD), we used national data to compare rates, patient characteristics, and outcomes of cholecystectomy for FGBD with the more defined diagnosis of biliary colic. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was reviewed for elective cholecystectomies from 2005-2013. The proportion of cholecystectomies performed for FGBD was assessed over time using a 2-sided Cochran-Armitage test for trend. Cholecystectomy for FGBD was compared with that for biliary colic using univariate analysis, multivariable logistic, and Cox proportional hazard regressions. RESULTS: Of 156,322 patients undergoing cholecystectomy, 5,161 (3.3%) had FGBD. FGBD as an indication for cholecystectomy remained stable over time (3.4% in 2006 to 3.2% in 2013, P = .29). Compared with biliary colic, patients with FGBD were more likely <50 years old, non-Hispanic white, female, and had a body mass index <25 (all P < .001), while comorbidities were similar (P > .05). While differences in outcomes were seen on univariate analysis, on multivariable analysis, only duration of stay was significantly less for FGBD than biliary colic. Surgery residents were involved in 61.2% of the biliary colic versus 53.9% of FGBD cases (P < .001). CONCLUSION: The rate of FGBD as an indication for cholecystectomy is not increasing overall, but cholecystectomy may be more commonly performed at nonacademic hospitals. While cholecystectomy for FGBD appears safe, the outcomes are comparable to cholecystectomy for biliary colic and thus are not without risk.