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Article 1
Evaluation of a Water-Soluble Contrast Protocol for Small Bowel Obstruction: A Southwestern Surgical Congress Multicenter Trial. Moskowitz EE, McIntyre RC, Burlew C,C Helmkamp LJ, Peltz ED, Coleman JR, Kovar A, Truitt M, Agrawal V, Onkendi E, Dev R, Diaz JJ, Eaton B, Campion E. Am J Surg. 2019 Dec;218(6):1046-1051.
Water-soluble contrast studies have been found in multiple studies to expedite the diagnosis and treatment of adhesive small bowel obstructions that will not respond to nonoperative management. Use of water-soluble contrast studies is included in the EAST Practice Management Guidelines for the evaluation and management of small bowel obstructions. This study by Moskowitz and colleagues was a retrospective multi-institutional study that examines whether a standardized water-soluble contrast (WSC) protocol can differentiate between small bowel obstructions that can be managed nonoperatively and those that require surgical intervention.
This was a retrospective review from five centers over a one year time period. Patients with adhesive small bowel obstructions (SBO) underwent a CT scan and were admitted to the Acute Care Surgery or Emergency General Surgery service. Unless there were sings of peritonitis or bowel compromise on admission, patients were managed according to the WSC protocol. This consisted of nasogastric tube placement and decompression for at least 6 hours prior to instillation of water- soluble contrast. Follow up radiographs were obtained at 12 and 24 hours. Failure of contrast to pass in 24 hours was considered a relative indication for surgery. Data was collected regarding length of stay, need for operation and complications.
Two hundred and eighty three patients were included in the study. Of those, 13% underwent immediate laparotomy due to possible bowel compromise. The overall complication rate for patients undergoing immediate surgery was 21%. Of the 197 patients who received WSC, 73% had successful passage of contrast within 24 hours. Almost all patients that had failure of contrast passage underwent surgery. Interestingly, there was a similar rate of small bowel resection between patients that underwent immediate laparotomy and those that underwent surgery after the WSC study. In comparing the immediate laparotomy group to the WSC laparotomy group, there was a statistically significant higher rate of complications in the WSC protocol patients (28.9%vs 21%). Most of these complications were infectious, with pulmonary complications being the second most frequent. Length of stay was longer in the WSC group but this was not statistically significant (9 vs 7.5 days).
While the authors were able to show that a WSC protocol can be safely used to differentiate between adhesive bowel obstructions that need surgical operative intervention and those that can be successfully managed conservatively, there remains a high rate of infectious and pulmonary complications for those patients that fail a WSC protocol. It is concerning that those patients that required laparotomy had a higher rate of complications than those that underwent immediate laparotomy. There was also a similar rate of small bowel resection between the two groups. While WSC protocols are able to safely and quickly identify patients that do not require surgery for their bowel obstruction, there should continue to be a focus on early identification of patients that will need surgery as the authors have shown that a delay in surgery results in a higher rate of complications.
Article 2
Gallstone Pancreatitis Admission versus Normal Cholecystectomy – A Randomized Trial (Gallstone PANC Trial). Mueck K, Wei S, Pedroza C, Bernardi K, Jackson M, Liang M, Ko T, Tyson J, Kao L. Ann of Surg. 2019 Sep; 270(3): 519-527.
Treatment of mild gallstone pancreatitis consists of supportive treatment and cholecystectomy during the hospitalization, usually after clinical and laboratory resolution of the pancreatitis.The timing of this cholecystectomy has recently been questioned. Earlier studies had suggested that cholecystectomy within the first 48 hours of admission resulted in a higher morbidity and mortality. The purpose of this pilot randomized trial was to determine if early cholecystectomy within 24 hours was feasible and assess the effects on complications and length of stay (LOS). The authors hypothesized that early cholecystectomy would result in a shorter LOS without an increase in complications.
This was a single center randomized trial at a safety net hospital that was capable of performing cholecystectomies 24 hours a day, 7 days a week. A total of 100 patients with gallstone pancreatitis were enrolled in the study over a 2 year time period. Once it was determined that the gallstone pancreatitis was mild, patients were randomized to either cholecystectomy within 24 hours or to standard cholecystectomy after clinical resolution of pancreatitis. There was a change in protocol halfway through the study that required a 12-hour observational period prior to surgery after 2 patients progressed to severe pancreatitis. Only one of these patients underwent cholecystectomy prior to developing worsening pancreatitis.
Total LOS was shorter in the early group compared to the control group (50 vs 77 hours). Postoperatie length of stay was the same between the two groups but the average time from admission to OR was 16 hours in the early group as opposed to 43 hours in the control group. Readmission rates were similar between groups. Postoperative ERCP was performed in 15% of early cholecystectomy patients as compared to 30% of delayed cholecystectomy patients. Half of all cholecystectomies in the early group were performed at night. The overall rate of complications was similar between the two groups but there was a higher rate of minor complications in the early group (15% vs 6%). The authors performed a Bayesian analysis that indicated that early cholecystectomy had a 72% probability of increased minor complications.
The authors were able to show that early cholecystectomy within 24 hours of presentation resulted in a shorter overall length of stay than standard cholecystectomy after resolution of pancreatitis. This shorter length of stay persisted after the change in protocol that mandated a 12-hour delay prior to surgery to ensure the patients did not have worsening pancreatitis. The development of severe pancreatitis in two patients in the early group is concerning but there were no further occurrences of this after the 12-hour delay was instituted. The decrease in length of stay may not be applicable to all institutions as the study hospital was able to perform cholecystectomies 24 hours a day with over half of surgeries being done at night. While there was an increased probability of minor complications, given the overall low rate of complications and study size, it is difficult to say how clinically significant this was. Interestingly, there was a lower rate of postoperative ERCP in patients that underwent early cholecystectomy, although the reason for this is unclear. This study shows promise for decreasing the length of stay for patients with mild gallstone pancreatitis, however, larger studies need to be done to ensure the decreased length of stay and that there is no increased rate of complications in patients undergoing early cholecystectomy.
Article 3
Supplementation with Lactobacillus reuteri ATCC PTA 4659 in patients affected by acute uncomplicated diverticulitis: a randomized double-blind placebo-controlled trial. Petruzziello C, Migneco A, Cardone S, Covino M, Saviano A, Franceschi F, Ojetti V. Int J Colorectal Dis. 2019 Jun;34(6):1087-1094.
Diverticulitis is an increasing frequent clinical problem in industrial countries. In this paper the authors did a double-blind, placebo RTC in patients with Acute complicated Diverticulitis (AUD).
The study included 88 patients divided equally in two groups. Group A as treated with Ciprofloxacin 400mg BID and metronidazole 500mg TID for one week plus Lactobacillus reuteri BID for 10 days. Group B patient were treated with the same antibiotics for one week plus placebo BID for 10 days. All patients completed a daily visual analog pain Scale (VAPS)for abdominal pain. The mean standard deviation and confident interval were obtained.
Groups were similar in age (60’s), CRP levels (A=68, B=71).
They found that the VAPS in group A improved significally during day 1-3, comparing with group 2. Also, CRP levels decreasing almost by half in group A in the first days of treatment.
Also, they found that the length of hospital stays decreased by one day for group A.
The author claim that this is the first study that evaluates probiotics in the treatment of AUD.
The flora has trophic and protective functions, contributes to the regulation of intestinal permeability, is involved in the processes of immunomodulation, and influences the motility of the gastrointestinal tract. There are useful bacteria that do not induce an inflammatory response and do not activate the signal pathways that lead to the secretion of TNFα.
The presence of lactobacillus reuteri decreases the inflammatory response and the patients get less bloating and also confirmed that the degree of histological inflammation and the level of C-RP seems to correlate with the severity of disease, as in IBD. With the early reduction in inflammatory index, and consequently the reduction in abdominal pain suffered by the patients, they were able to discharge these patients faster (93 h compared with 113 h for the placebo group. In conclusion adding L. reiteri to treatment of AUD is beneficial for the patient.
Article 4
Well Leg Compartment Syndrome After Prolonged Pelvic Surgery: Launch of United Kingdom and Ireland Multidisciplinary Clinical Guidelines. Soop M, Carlson G. Dis Colon Rectum. 2019 Oct;62(10):1150-1152.
This article talks about the development of compartment syndrome in one or both lower extremities after prolonged pelvic surgery. The incidence Well leg compartment syndrome (LWCS) has been reported from 0.20%to 0.03%. The mechanism of lower leg compartment Syndrome, in the absence of trauma, is due to ischemia-reperfusion after prolonged position of patient in modified lithotomy position. Now with the increased in minimal invasive procedures (laparoscopic and robotics), patients are positioned in the reverse Trendelenburg position and also increased intrabdominal pressure that leads to hypotension and vasoconstriction. These leads to edema, increasing compartment pressures. It is important to keep it in mind because it could happen in any pelvic surgery <90min, the longer the surgical time, the higher the risk. There are new guidelines in the British Journal of surgery.
https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11177
LWCS should be on the list of differential diagnosis after pelvic surgery when patient presents with lower limb pain. Diagnosis is clinical and emergent fasciotomy should be done to avoid further nerve damage or limb threatening.
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