Impact of Race on the Surgical Management of Adhesive Small Bowel Obstruction.

BACKGROUND: Small bowel obstruction (SBO) represents roughly 15% of admissions by general surgeons. Management of SBO relies heavily on provider judgment, including decisions on how long to try nonsurgical management and whether to use a laparoscopic or open approach when surgery is needed. Given the subjective nature of these decisions, it is unknown if patient race influences management of SBO. STUDY DESIGN: The National Surgical Quality Improvement Program was used to identify patients who underwent adhesiolysis or small bowel resection for adhesive SBO between 2010 and 2015 (n = 13,896). Adjusted logistic regression models incorporating patient comorbidity, American Society of Anesthesiologists (ASA) class, and emergency status were used to analyze odds of receiving surgery after 5 days from hospital admission (Eastern Association for the Surgery of Trauma guidelines) and of undergoing an open operation. RESULTS: Patients who waited more than 5 days for a procedure had greater adjusted odds of postoperative complication (odds ratio [OR] 1.56 95% CI 1.37 to 1.79) compared with those waiting 5 days or less. Similarly, open procedures had higher odds of complication compared with laparoscopic (OR 2.31 95% CI 2.00 to 2.68). Regression analysis demonstrated that black patients were significantly more likely than white patients to wait more than 5 days for surgery (OR 1.31 95% CI [1.13-1.53]) and undergo open surgery (OR 1.56, 95% CI 1.36 to 1.79). There was no statistical difference for Hispanics patients waiting more than 5 days (OR 0.98, 95% CI 0.73 to 1.31) or receiving open surgery (OR 0.84, 95% CI 0.70 to 1.01) compared with white patients. CONCLUSIONS: Clinical decisions regarding SBO management differ based on patient race. Future studies focusing on the surgical decision-making process and the influence of bias are needed.

Trends in demographics and management of obstructing colorectal cancer.

INTRODUCTION: Obstructing colorectal cancer (CRC) has an aggressive clinical course and poorer prognosis. With the increasing incidence and differing clinical and pathologic spectrum of CRC among Black patients, as well as a paucity of African studies, regional analysis is required. Our aim was to describe the demographics and management of obstructing CRC among the different racial groups in South Africa and to compare these parameters with international standards. PATIENTS AND METHODS: Patients referred to Inkosi Albert Luthuli Central Hospital, Durban, South Africa, with CRC between 2000 and 2012 were followed prospectively. Demographic information, site of obstruction, and management of patients who underwent emergency surgery for malignant large bowel obstruction were analyzed separately. RESULTS: CRC was diagnosed in 1,425 patients. A total of 203 three patients (14.3 %) required emergent treatment for acute large bowel obstruction. The mean age at presentation with obstructing CRC was 59 years. Black patients presented significantly younger (50 years) than White (64), Indian (60), or Colored (61) patients (p < 0.001). The most common sites of obstruction were the sigmoid colon and rectum. A total of 58 patients (29 %) had concomitant metastatic disease. No difference was found between race, sex, and sex per race in patients with concurrent metastatic disease (p = 0.227, p = 0.415, p = 0.798, respectively). Of the 203 patients, 128 (63 %) were managed by resection, 37 (18 %) by colonic stenting, 35 (17 %) by colostomy, and 3 (2 %) by colonic bypass. Stenting was unsuccessful in six patients. CONCLUSION: Tumor location of patients presenting with obstruction is comparable to that cited in international literature; however, the age of presentation among Black patients is more than a decade earlier than in other ethnic groups. Surgical management should be individualized. Stenting remains a reliable alternative in select cases.

Obstrução intestinal pós-gastroplastia redutora pela técnica de higa para tratamento da obesidade mórbida: aspectos por imagem / Intestinal obstruction after Roux-en-Y gastric bypass by Higa's technique for treatment of morbid obesity: radiological aspects

OBJETIVO: O objetivo deste estudo foi descrever os principais aspectos radiológicos encontrados nas obstruções intestinais pós-operatórias em pacientes submetidos a derivação gastrintestinal em Y de Roux pela técnica de Higa. MATERIAIS E MÉTODOS: Foram estudados 10 pacientes com obstrução intestinal no pós-operatório de gastroplastia redutora, examinados entre novembro de 2001 e abril de 2006. Os casos foram obtidos em sete instituições hospitalares distintas. RESULTADOS: Nos 10 pacientes, a obstrução ocorreu em alça de delgado, sendo cinco por hérnia interna, três por brida, um por hérnia umbilical e um por intussuscepção gástrica. Em quatro pacientes a obstrução ocorreu precocemente (até o sétimo dia de pós-operatório) e em seis aconteceu tardiamente (entre o terceiro mês e cinco anos de pós-operatório). CONCLUSÃO: Todos os casos de obstrução intestinal ocorreram ao nível do intestino delgado. A hérnia interna foi a causa mais freqüente, seguida de brida. Outras causas foram hérnia umbilical e intussuscepção gástrica.

OBJECTIVE: The aim of this study is to describe the main radiological aspects of postoperative intestinal obstruction in patients submitted to Roux-en-Y gastric bypass by means of the Higa's technique. MATERIALS AND METHODS: A total of 10 patients presenting with postoperative intestinal obstruction following a gastric reduction procedure were evaluated in the period between November 2001 and April 2006, in seven different medical centers. RESULTS: In the ten patients, the obstruction occurred in the small bowel, five of them because of internal hernias, three because of adhesions, one because of an umbilical hernia and one because of intussusception. Four patients presented obstruction early in the postoperative period (by the seventh post-op day), and six, late in the postoperative period (between the third month and the fifth year). CONCLUSION: All of the cases of intestinal obstruction were found in the small bowel. Internal hernia was the most frequent cause, followed by adhesion. Other causes included umbilical hernia and intussusception.

Prospective integration of cultural consideration in biomedical research for patients with advanced cancer: recommendations from an international conference on malignant bowel obstruction in palliative care.

In the setting of an international conference on malignant bowel obstruction as a model for randomized controlled trials (RCTs) in palliative care, we discuss the importance of incorporating prospective cultural considerations into research design. The approach commonly used in biomedical research has traditionally valued the RCT as the ultimate "way of knowing" about how to best treat a medical condition. The foremost limitation of this approach is the lack of recognition of the impact of cultural viewpoints on research outcomes. We propose that interest relevant to cultural viewpoints should be emphasized in conceptualizing and interpreting research questions, designs, and results. In addition to recognizing our cultural biases as individuals and researchers, we recommend two major shifts in designing and implementing RCTs: 1) inclusion of a multidisciplinary team of researchers to inform the diversity of perspectives and expertise brought to the research, and 2) use of mixed methods of inquiry, reflecting both deductive and inductive modes of inference.

Meconium ileus-like condition in Chinese neonates.

Between January 1985 and May 1990, 16 neonates were treated for meconium ileus (MI) at this hospital. All babies were born to Chinese couples. Seven of them were premature, but none of them weighed less than 1,000 g. Eight patients underwent operations either because of mistaken diagnosis, as ileal atresia or long-segment Hirschsprung's disease, or because of complicated MI, including two meconium peritonitis and one associated with ileal atresia. Gastrograffin enema was successful in management of eight uncomplicated MI. The albumin content in the meconium of the last nine cases, including four complicated cases, ranged from 9.2 to 93.3 mg/g dry meconium. Usually, albumin is not present in normal meconium. All cases received sweat test, which were negative. Three patients died in the follow-up period. Sepsis of unknown origin, multiple congenital anomalies, and severe metabolic problems were the causes of death. The other 13 patients are doing well. They have exhibited no pulmonary or digestive problems during their follow-up period, which ranged from 11 months to 5 years. They are healthy and receive regular diets. Growth and development are appropriate for their age groups.