RESUMEN
INTRODUCTION: Early recognition of bowel ischemia is critical in patients suffering from acute adhesive small bowel obstruction (ASBO). Recent studies attempted to propose a score combining clinical and radiological factors to predict the risk of bowel ischemia in patients with ASBO. This study aimed to compare and validate the existing clinical scores with a cohort of surgical patients. METHODS: We conducted a retrospective study including all ASBO cases admitted to our institution between January 1, 2005 and December 31, 2019. Based on three existing clinical scores, we calculated the risk of bowel ischemia for each patient. We then divided the cohort into groups based on the risk for bowel ischemia. For each risk-based category, the proportion of patients who underwent surgical resection and were found to have evidence of ischemic bowel was calculated. RESULTS: A total of 160 patients presenting with 217 episodes of acute ASBO were included. One hundred seventy-one (78.8%) cases were managed nonoperatively while 46 cases (21.2%) required surgery. Sixteen patients (7.3%) were eventually found to have ischemic bowel while 13 required small bowel resection (5.9%). All three clinical scores showed correlation between the calculated risk of ischemia and the intraoperative finding of ischemia. However, all three scores overestimated ischemia rates in the high-risk groups, yielding a PPV of 8.3%-28.5% and a NPV of 93.3%-94.7%. CONCLUSIONS: Current clinical scores for predicting bowel ischemia in patients with ASBO are of high value in ruling out ischemia, yet are of extremely low sensitivity, warranting an overly aggressive and unnecessary surgical approach.
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Obstrucción Intestinal , Isquemia Mesentérica , Humanos , Adherencias Tisulares/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Obstrucción Intestinal/cirugía , IsquemiaRESUMEN
BACKGROUND: The aim of this study is to investigate the outcomes of conservative management of non-complicated acute appendicitis (AA) using our unique institutional protocol, and to compare between these and the outcomes of operative management. METHODS: Patients admitted to our institution between March 2016 and October 2019 with non-complicated AA were grouped according to their initial management: non-operative versus surgical. Our unique protocol for non-operative management includes: pain < 3 days; afebrile upon admission; non-gravid; WBC <15,000 (× 109/L); CRP < 5 mg/dl; appendix diameter < 1 cm; no appendicolith on imaging; no prior episode of AA; no history of Inflammatory Bowel Disease; no evidence of peritonitis on physical examination. The primary outcome measured was failure of non-surgical management during the index admission. Secondary outcomes included recurrence rate, readmissions, complications, length of antibiotic treatment and length of stay (LOS). RESULTS: A total of 695 patients were included, 436 in the operative group and 259 in the non-surgical treatment group. The mean follow-up time was 1004.9 ± 205.7 days. Patients initially treated conservatively rarely required surgery during their index admission (6.9%). Recurrence rate was 19.1% after a mean follow up of 33.4 months. The overall failure rate of conservative management was documented in 20.8% of the patients. The complication rate was higher in those treated with upfront surgery (1.6% vs. 0.4%, p < 0.001). The overall LOS was not statistically different between the groups. CONCLUSIONS: Our composite protocol for non-surgical management of non-complicated AA results in a low failure rate. A well calculated patient treatment allocation in non-complicated AA can advocate for wide-spread use of the conservative approach.
Asunto(s)
Apendicitis , Apéndice , Peritonitis , Enfermedad Aguda , Antibacterianos/uso terapéutico , Apendicectomía , Apendicitis/tratamiento farmacológico , Apendicitis/cirugía , Humanos , Tiempo de Internación , Resultado del TratamientoRESUMEN
BACKGROUND: The effect of age and gender on outcomes of revisional bariatric surgery has not been assessed. METHODS: A retrospective analysis of patients undergoing revision from laparoscopic adjustable gastric banding (LAGB) to laparoscopic roux en Y gastric bypass (LRYGB) between 2007 and 2017 was performed. Patients were divided according to gender and age (<50 andâ¯≥â¯50 years), and the outcomes of the subgroups were compared. RESULTS: During the study period, 161 revisional LRYGBs were performed. Postoperative percentage of total body weight loss was comparable between the subgroups. No significant difference was observed between the groups in the improvement/resolution of comorbidities. Overall early complication rates were comparable, however major postoperative bleeding was more common in older patients (6.7 vs. 0.9%, pâ¯=â¯0.03). More late complications were demonstrated in females when compared to males (14.3 vs. 2.0%, pâ¯=â¯0.02). CONCLUSIONS: Revisional LRYGB after failed LAGB yields acceptable results, regardless of patient gender and age.