Clinical strategies for the management of intestinal obstruction and pseudo-obstruction. A Delphi Consensus study of SICUT (Società Italiana di Chirurgia d’Urgenza e del Trauma)
1 Emergency Surgery Unit, Surgical and Medical Department of Translational Medicine, Sant’Andrea Hospital, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Rome, Italy
2 Management and Control System Unit, Director of Hospital Medical Data Archiving System, Sant’Andrea Hospital, Faculty of Medicine and Psychology, University of Rome “La Sapienza”
3 Emergency and Trauma Surgery Section, Department of Applications and Innovative Technologies for Surgery, Faculty of Medicine and Surgery, University of Bari, Italy
4 Department of Sciences and Medical-Surgical Biotechnology, Polo Pontino Terracina, Faculty of Pharmacy and Medicine, University of Rome “La Sapienza”, Rome, Italy
5 Department of Surgical Sciences, Umberto I Hospital, Faculty of Medicine and Odontology, University of Rome “La Sapienza”, Rome, Italy
6 Emergency Surgery Unit, M. Bufalini Hospital, AUSL Cesena, Italy
7 Emergency Surgery Unit, Torrette Hospital, Faculty of Medicine and Surgery, Polytechnic University of Marche, Ancona, Italy
8 OBOW-SICUT Collaborative Study Group (see Appendix 1)
BACKGROUND: Intestinal obstructions/pseudo-obstruction of the small/large bowel are frequent conditions but their management could be challenging. Moreover, a general agreement in this field is currently lacking, thus SICUT Society designed a consensus study aimed to define their optimal workout. METHODS: The Delphi methodology was used to reach consensus among 47 Italian surgical experts in two study rounds. Consensus was defined as an agreement of 75.0% or greater. Four main topic areas included nosology, diagnosis, management and treatment. RESULTS: A bowel obstruction was defined as an obstacle to the progression of intestinal contents and fluids generally beginning with a sudden onset. The panel identified four major criteria of diagnosis including absence of flatus, presence of >3.5 cm ileal levels or >6 cm colon dilatation and abdominal distension. Panel also recommended a surgical admission, a multidisciplinary approach, and a gastrografin swallow for patients presenting occlusions. Criteria for immediate surgery included: presence of strangulated hernia, a >10 cm cecal dilatation, signs of vascular pedicles obstructions and persistence of metabolic acidosis. Moreover, rules for non-operative management (to be conducted for maximum 72 hours) included a naso-gastric drainage placement and clinical and laboratory controls each 12 hours. Non-operative treatment should be suspended if any suspects of intra-abdominal complications, high level of lactates, leukocytosis (>18.000/mm3 or Neutrophils >85%) or a doubling of creatinine level comparing admission. Conversely, consensus was not reached regarding the exact timing of CT scan and the appropriateness of colonic stenting. CONCLUSIONS: This consensus is in line with current international strategies and guidelines, and it could be a useful tool in the safe basic daily management of these common and peculiar diseases.
Keywords
Delphi study
Intestinal obstruction
Large bowel obstruction
Pseudo-obstruction
Small bowel
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