Early postoperative small bowel obstruction: open vs laparoscopic.

BACKGROUND: The window for safe reoperation in early postoperative (<6 weeks) small bowel obstruction (ESBO) is short and intimately dependent on elapsed time from the initial operation. Laparoscopic procedures create fewer inflammatory changes than open laparotomies. We hypothesize that it is safer to reoperate for ESBO after laparoscopic procedures than open. METHODS: Review of patients who underwent re-exploration for ESBO from 2003 to 2009 was performed. Based on the initial operation, patients were classified as "open" or "laparoscopic." The Revised Accordion Severity Grading System was used to define complications as minor (1 to 2) or severe (3 to 6). RESULTS: There were 189 patients identified (age 55 years, 48% male): 130 open and 59 laparoscopic. Adhesive disease was more common (65% vs 42%, P < .01), while strictures were less frequent (5% vs 14% P = .03), in the open group. The open group had a greater rate of malignancy, days to re-exploration, and severity of complications. There was no difference in the rates of minor complications, enterotomy, and mortality. ESBO after laparoscopic surgery was more commonly caused by a focal source (85% vs 63%). Eighty-three patients (64 open, 19 laparoscopic) underwent re-exploration at or beyond 14 days. Within this subgroup, there were more severe complications (25% vs 5%) after open procedures with equivalent mortality (4% vs 0%). CONCLUSIONS: Laparoscopic approaches confer a lower rate of adhesive disease and severity of complications in early SBO as compared with open surgery even if performed after 2 weeks of index procedure.

Use of the Gastrografin challenge in patients with a history of abdominal or pelvic malignancy.

BACKGROUND: The Gastrografin (GG) challenge was developed to predict the need for operative management in patients with small bowel obstruction (SBO). Although clinical trials have demonstrated that it is an effective diagnostic and therapeutic modality, these studies excluded patients with a history of abdominal/pelvic malignancy. This study aims to examine the outcomes of the GG challenge for patients with a history of abdominal/pelvic malignancies. METHODS: Institutional review board approval was obtained to review retrospectively patients admitted with SBO in 3 separate categories: Group 1, patients presenting between 2010 and 2012 with SBO who received the GG challenge and had a concurrent history of abdominal or pelvic malignancy; group 2, patients presenting between 2010 and 2012 with SBO who underwent the GG challenge but did not have a concurrent history of abdominal or pelvic malignancy; and group 3, patients presenting between 2007 and 2010 (before our incorporation of the GG challenge protocol) with SBO and a concurrent history of abdominal or pelvic malignancy who did not receive GG . Two distinct comparisons were made. The first analysis was made between groups 1 and 2. The second comparison was performed comparing patients from groups 1 and 3. RESULTS: A total of 237 patients (74 group 1, 83 group 2, 80 group 3) were identified with a mean age of 69.1 years (range, 20-101); 115 were male (48%).There were no adverse events related to GG administration in our study. Analysis of groups 1 and 2 showed similar rates of exploration (25% vs 18%) and complications (32% vs 24%); however, mortality was greater among patients with history of malignancy at 12 months (26% vs 7%). Both groups had similar readmission rates for SBO, as well as exploration upon readmission. Analysis between groups 1 and 3 showed that the need for operative exploration at index admission was less in patients who underwent the GG challenge (26% vs 41%); however, hospital duration of stay was similar (8 vs 9 days). There was no difference in SBO recurrence at 12 months (28% vs 26%); however, mortality was significantly greater among patients not receiving GG (26% vs 41%). CONCLUSION: The GG challenge was safe and effective in patients presenting with SBO and a history of abdominal or pelvic malignancy. As a result, GG has the potential to improve these terminal patients' quality of life.

Outcomes of chemical component paralysis using botulinum toxin for incisional hernia repairs.

BACKGROUND: Botulinum toxin A (BTX) confers flaccid paralysis and pain modulation when injected into a muscle. We hypothesized that long-term paralysis of the abdominal wall musculature (i.e., chemical component paralysis, CCP) would benefit incisional hernia repair (IHR) by decreasing postoperative pain, the use of opioid analgesia, and thus opioid-related side effects. METHODS: Adult patients who underwent elective IHR with preoperative CCP (n = 22) were compared to concurrent matched controls (n = 66, 1:3 ratio) based on age (±5 years), sex, body mass index (±5 kg/m(2)), history of hernia recurrence (0 vs. ≥1), and type of repair (open vs. laparoscopic). BTX was injected under ultrasonographic guidance into the transversus abdominis and internal and external oblique muscles at three sites bilaterally (300 units total). RESULTS: Patients who underwent IHR with CCP used significantly less opioid analgesia (mean ± SD morphine equivalents) when compared to controls on hospital days (HDs) 2 and 5: HD2, 48 ± 27 versus 87 ± 41; HD5, 17 ± 16 versus 48 ± 45. Likewise, CCP patients reported significantly less pain (visual analogue scale 1-10) when compared to controls on HD2 (5.2 ± 1.5 vs. 6.8 ± 2) and HD4 (3.6 ± 1.2 vs. 5.2 ± 1.9): all p < 0.007 (Bonferroni adjusted). There was no difference in postoperative complications (surgical site, 9 vs. 14 %), opioid-related adverse events (ileus 5 vs. 5 %), hospital stay (4 ± 3 vs. 3 ± 2 days), or hernia recurrence (18 months mean follow-up: 9 vs. 9 %). CONCLUSIONS: Despite similar multimodality treatment of postoperative pain after IHR, patients who underwent CCP required significantly less opioid analgesia and reported less pain.