case study of abdominal surgery

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PATIENT CASE STUDY: REBUILDING A PATIENT’S LIFE NOT JUST THEIR ABDOMINAL WALL – EXPERIENCE FROM A TERTIARY HERNIA CENTRE ON THE IMPACT OF ABDOMINAL WALL RECONSTRUCTION ON QUALITY OF LIFE

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A Birch, F Cocciolo, I Alabbasi, PATIENT CASE STUDY: REBUILDING A PATIENT’S LIFE NOT JUST THEIR ABDOMINAL WALL – EXPERIENCE FROM A TERTIARY HERNIA CENTRE ON THE IMPACT OF ABDOMINAL WALL RECONSTRUCTION ON QUALITY OF LIFE, British Journal of Surgery , Volume 111, Issue Supplement_5, May 2024, znae122.259, https://doi.org/10.1093/bjs/znae122.259

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Abdominal wall reconstruction is a transformative intervention, significantly improving the quality of life for individuals with complex defects. This paper focuses on sharing a patient's experience post-surgery.

The patient presented with a complex incisional hernia following a laparotomy, Hartmann’s procedure and splenectomy for perforated diverticular disease. Their CT scan showed a 16.5 × 17.5 cm defect, with a separate component involving their colostomy and lateral displacement of their muscle complexes. The hernia significantly impacted the patient's quality of life, manifesting as daily moderate pain that hindered routine activities. They required daily dressings and antibiotics due to skin changes over the hernia. Furthermore, dissatisfaction with the cosmetic appearance of the hernia contributed to the overall burden on the patient.

The patient underwent pre-operative botulinum toxin injections six weeks prior to their abdominal wall reconstruction. They received 200 units divided equally between internal and external obliques. During their surgery they required a left sided transversus abdominus release and an >5cm mesh overlap was achieved in all directions. A post-operative CT scan conducted ten days after the surgery revealed no complications. The patient's recovery progressed well, leading to their discharge 12 days post-surgery.

The patient was reviewed nine months post-surgery. Expressing high satisfaction with the surgical outcome, they conveyed a profound positive impact on their quality of life. The patient's newfound confidence in the improved cosmesis of their hernia was evident. Overall, the surgery proved transformative, liberating the patient from the burdens of frequent medical appointments and instilling a renewed sense of self-assurance.

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Home > Books > Abdominal Surgery - A Brief Overview

Postoperative Follow-Up and Recovery after Abdominal Surgery

Submitted: 23 November 2020 Reviewed: 15 April 2021 Published: 21 May 2021

DOI: 10.5772/intechopen.97739

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Abdominal Surgery - A Brief Overview

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Postoperative patient care has several components: - surveillance, − prevention of complications associated with surgical disease or other preexisting comorbidities, − specific postoperative treatment of the surgical disease and its complications. While these distinctions are purely didactic, the postoperative care merges into an active surveillance with a higher level of standardization than it would seem at first glance. Computing, interpreting and integrating signs and symptoms with active search of proofs by lab tests or other paraclinical explorations highly depends on skills and dedication of the entire healthcare team. Those attributes gained through continuous theoretical preparation but validated by current practice bring added value, always in favor of the patients’ best interests. In this chapter, we propose to explore the main clinical and paraclinical means and tools that can improve the outcomes of surgical procedures for a faster and safer recovery. We will also discuss the need for different types of surgical bed drains placement and their management, the use of antibiotics and thrombotic event prophylaxis.

• postoperative
• complication
• prophylaxis

Author Information

Stelian stefanita mogoanta *.

• General Surgery Department, University of Medicine and Pharmacy of Craiova, Romania

Stefan Paitici

Carmen aurelia mogoanta.

• ENT Department, University of Medicine and Pharmacy of Craiova, Romania

*Address all correspondence to: [email protected]

1. Introduction

The surgical act, defined as the time that a surgeon effectively operates on the patient, remains the center of surgical therapy, however, it is increasingly clear that the preoperative and more importantly the postoperative care can enhance or unfortunately compromise the results of a technically successful surgery. For reducing the mortality and morbidity rates in the postoperative period, it is crucial to identify risk factors, prevent and treat as soon as possible any deviation of the patient state from the normal rehabilitation course. Timely interventions reduce the impact of the negative events in the patient’s recovery. Early recognition of signs and symptoms by close surveillance is the key and starting point for active surveillance. This allows targeted lab testing or imaging (if needed) to rapidly identify any undesired event in patient recovery and allow for specific and proper action.

To monitor the operated patient, we have at our disposal the clinical and paraclinical parameters. The patient’s temperature, despite being a general and non-specific parameter, is one of the most important and easy to monitor.

During the follow-up period of the surgical patient, the temperature is usually measured at least twice a day, in the morning and in the afternoon, and whenever there is a suspicion of fever. The determinations are included in the observation sheet completing the temperature graph whose oscillations become suggestive in a clinical context. A single febrile rise, below 38 degrees Celsius can often be caused by the resorption of blood degradation products from the operative wound or secondary to the excessive maintenance of a drainage tube, without major pathological significance [ 1 ]. However, the persistence of the fever with the configuration of “saw teeth” on the thermal chart suggests the development of a septic process. The first to be checked is the surgical site, then the lung and urinary system, as these are the most frequent sites of infection after surgery. Particular attention should be paid to the occult causes of fever such as endocarditis, phlebitis, lamellar atelectasis that should be systematically searched for in the context of an unjustified febrile syndrome with an apparently good evolution in the operative site. In a large cohort study [ 2 ], the most common causes of fever development were stratified a few days after surgery. On the day of surgery, cardiac pathology and specific myocardial infarction seem to be the most common, then pulmonary pathology – pneumonia and atelectasis seem to cause fever in days 1–3 postoperatively. Urinary infections usually occur in 2–3 days postoperatively but can also begin later. From day 4 to 30 postoperatively, superficial or profound surgical site infections become the main cause for fever development, while thrombosis can cause fever at any time between the day of surgery and postoperative day 30. When the febrile ascension appears suddenly on the fifth day after surgery, without signs of wound infection anastomosis dehiscence should be suspected, however, it can also be caused by thrombophlebitis. Therefore, we can conclude that fever is a general sign that should always be interpreted in accordance with other signs and symptoms but it is an alarming sign that should lead to careful and complete physical examination and laboratory tests or imaging studies evaluated on a case-by-case basis.

3. Supervision of the cardiovascular system

Cardiovascular system stability is crucial in the postoperative evolution of the patient. Complex surveillance is needed in many cases and the rehabilitation measures must be intensive and prompt, conducted in most cases by the intensive care specialist or cardiologist. However, the surgeon must be prepared to recognize cardiac risks and main syndromes and even manage the patient until one of the above mentioned specialists are available.

Heart rate is systematically monitored several times a day. Immediately postoperatively, the pulse rate is usually higher than normal with a decreased amplitude, may be justified by intra operative blood loss, which may remain insignificant in the overall economy of the patient’s healing, or by anesthetic drugs, the extent of surgical “aggressiveness”, pain, etc. As these factors are progressively corrected, the heart rate should return to normal. Additional oxygen administration can help achieve a faster normal rate as it improves tissue oxygenation [ 3 ]. It is very important to compare the pulse frequency with the values ​​noted preoperatively taking into account the patient’s underlying pathology (thyroid, heart, etc.). The pulse with increasing frequency from one determination to another, with a small amplitude that becomes progressively filiform, associated with hypotension in a sweaty and pale patient, may be caused by a bleeding at the operating site (which is not always in the drain tube or in the container); this may require analysis of reoperation for hemostatic purposes. Tachycardia with low pulse amplitude and a decrease in blood pressure that occurs on days 4–6 postoperatively, may indicate a septic complication or anastomosis dehiscence. On the other hand, bradycardia is however associated with increased cardiac, pulmonary, renal and pain-related morbidity at 3 and 5 days after surgery [ 4 ]. The discovery of arrhythmias whether extrasystolic or atrial fibrillation as a new event, requires rapid correction of ionic and hydric imbalances and the search for a septic process, the most likely causes in this context. Both bradycardia and arrythmias always require a postoperative cardiac consult [ 4 , 5 ].

Blood pressure is determined at least twice a day. The recorded values ​​are interpreted in a dynamic clinical context, always compared with the normal values ​​of the patient determined preoperatively. Low blood pressure levels ​can be found immediately postoperatively, in conditions of shock, dehydration, bleeding or heart failure, etc. All these causes of low blood pressure require immediate and accurate diagnosis and correction as they bring increased mortality [ 6 ]. Elevated blood pressure levels ​​occur especially in patients with a history of hypertension in the context of an exaggerated postoperative catecholamine reaction, fluid overload or inadequate pain control. When they exceed certain values, ​​beyond physiological variations, both increases and decreases in blood pressure values ​​must be promptly corrected to prevent cerebral or cardiac events or ischemia of a recent anastomosis [ 7 , 8 ]. Due to the high complexity of the measures required, it is recommended that an unstable cardiovascular patient be transferred to the intensive care unit and evaluated by a cardiologist [ 8 ].

4. Respiratory surveillance and care

The quality of respiratory function has a major impact on the patient’s postoperative recovery, especially after major surgery. Immediately postoperatively, the anesthetist cleans the oropharyngeal and orotracheal cavities by suction to evacuate excessive secretions; this should be done easily so as not to increase or trigger local inflammation and spasm. Additional oxygen administration (via facemask or nasal tube) is recommended to reduce the effort of the respiratory muscles. In patients with ventilatory deficit, a high back position of 30–40 degrees can be adopted [ 9 ]; this improves respiratory dynamics and promotes the drainage of secretions [ 10 ]. For this purpose, back percussion is usually performed several times a day with the patient in sitting position, followed by respiratory toilet. The patient is encouraged to take deep breaths in order to relax and open the alveolar spaces thus reducing the ventilation “dead spaces” [ 9 , 10 , 11 ]. Under conditions of tracheobronchial fluid overload with excessive secretions, expectorants and mucolytics may be administered [ 12 ]; this improves drainage and reduces the effort of coughing. In such conditions, the patient is encouraged to cough in a controlled and effective manner, with the protection of the abdomen [ 13 ] (the most common site of surgery) either by gentle external pressure exerted by patient, doctor or nurse (as appropriate), or by using means of abdominal restraint like girdles. Prolonged, inefficient coughing may result in undue strain and tension on the surgical wounds, increasing the risk of evisceration or eventration. Aerosol solutions can be very useful [ 14 ] administered 2–3 times a day by nebulization for 5–10 minutes helps to “dry” or “thin” of the secretions as needed. It should be noted that postoperative pneumonia is one of the most common causes of significant morbidity and mortality after major surgery [ 9 , 10 , 11 ]. Prophylactic or therapeutic antibiotic therapy may not protect the patient from such a complication if excessive secretions remain undrained in the tracheobronchial tree [ 15 ]. The impact of a deficient oxygenation is systemic [ 16 , 17 ], manifested at the level of the operative site (with the hypooxygenation of an anastomosis for example), at the cardiac level (decompensation of an ischemic heart disease), cerebral, etc. However supplemental oxygen should not be administered on a regular basis, but only when the oximetry drops under 90–92%, due to secondary risks of hyperoxia [ 18 , 19 ]. The presence of prolonged, productive cough, especially when associated with fever and altered general condition, becomes an indication for a chest X-ray in order to capture changes responsible for the occurrence of this symptomatology and take appropriate measures [ 20 , 21 ]. In this context, the findings suggest that pneumonia is a strong indication for antibiotic therapy. Irritant cough associated with sore throat and hoarseness, reported by the patient, are elements that draw attention to a digestive reflux with secondary aspiration in the airways and glottis irritation. The situation is not unusual in conditions of prolonged postoperative intestinal paresis. In such cases, the first goal is to combat gastric stasis and hyper pressure and the most rapid way is by placing a nasogastric decompression tube. If we already have a nasogastric tube in position, we need to ensure its permanent patency because the tube can be obstructed with cloths, fibrin deposits partially digested food or gastric mucosa. Otherwise, the tube becomes a reflux promoting factor by keeping the cardia open and incompetent [ 22 ]. Concurrently adopting a semi-sitting position (maintained also during sleep) to prevent or reduce reflux is an extremely useful element in combating Mendelson’s syndrome (aspiration of the digestive fluid with acid content in the patient airways).

5. Surveillance of the excretory system

It is usually done by tracking the quantity and quality of urine output over a given time and more importantly in 24 hours. All patients undergoing medium and major abdominal surgery usually have a urinary catheter placed under anesthesia [ 23 ]. Catheter placement should be performed under sterile conditions, usually in preanesthetic room or on-table [ 24 ] to avoid infection, bladder injury during surgery, and to accurately monitor renal function during surgery. There are numerous causes of acute kidney injury or otherwise low urine output in the perioperative period, the risk being reported up to 5–10% in surgical patients [ 25 ]. In the immediate postoperative setting, low flow and concentrated urine indicate a good renal function but poor hydration of the patient or a state of shock due to blood loss or impaired cardiovascular function. Decreased urinary flow that occurs under conditions of proper hydration and previously normal renal function may be an indicator of fluid retention in the setting of third spacing, abdominal compartment syndrome or blood transfusions adverse reactions [ 10 , 25 ]. If this event occurs within 4 to 6 days postoperatively, it is usually secondary to the development of fistular or suppurative complications at the site of surgery, alerting the surgeon and allowing a prompt diagnosis of the complication. Failure to recognize the causes and the attempt to obtain adequate diuresis can lead to overloading the patient with fluids; this impairs the function of all the systems up to acute pulmonary edema or cardiac decompensation by increased preload.

Hyperchromic urine also occurs in conditions of mechanical jaundice when the urine turns intensely yellow to brown due to the renal elimination of soluble bile pigments [ 26 ]. The presence of large amounts of urobilinogen in urine usually indicates the hemolytic or hepatocellular nature of jaundice. Hematuria is the evacuation of blood into the urine. Bleeding can be located at any level of the urinary tract from the kidneys to the urethra and usually denotes an intraoperative lesion or clotting disorder. Hematuria can be microscopic and constantly appears after pelvic or retroperitoneal surgery [ 27 ] or macroscopic - when the red color of the urine is obvious, sometimes with deposits and blood clots to the point of obvious blood (Gross hematuria). Usually, hematuria caused by minor intraoperative lesions or produced at the placement of the urethro-bladder catheter is self-limiting. Persistent hematuria requires a complete specialist diagnosis. Hemoglobinuria defines hyperchromic urine, purple to dark brown that occurs during major hemolysis after transfusion accidents [ 28 ]. Early recognition is extremely important because if undiagnosed and subsequently untreated, it can precipitate acute irreversible renal failure by blocking glomerular filtration.

The proper timing of catheter removal is debatable, numerous studies and metanalyses have addressed this question as the risk of urinary infections increases with the duration of catheterization. For abdominal surgery that does not involve the genitourinary systems or pelvic surgery it seems that the optimal timing of catheter removal is the first postoperative day [ 29 ] which in most cases coincides with the time when the patient becomes ambulatory. However, for major surgery (extensive dissection, usually for cancer) involving the pelvic organs or requiring a longer period of immobilization, the catheterization period can be extended to 3–6 days or even longer, adapted to the clinical needs [ 29 ]. For instance, whenever the bladder is sutured (after iatrogenic lesions or deliberated partial resection) the urinary catheter should be left in place for at least 10–14 days.

6. Digestive system surveillance

The digestive system is the most common surgical site in general surgery, hence the special attention paid to its care. Systematic clinical examination can provide valuable information about the patient’s progress, adapting postoperative measures for an eventless and rapid recovery.

Usually forgotten or neglected, oral cavity inspection provides information about the patient’s hydration level; dry oral mucosa, for instance, requires an increase in fluid intake. The presence of whitish deposits on the lingual mucosa may suggest candidiasis infection caused by prolonged antibiotic use, while red depapillated glossy mucosa suggests iron deficiency. Toileting of the oral cavity by brushing and washing with antiseptic solutions is almost as important as postoperative wound care, as germs ingested at this level colonize and contaminate the lower levels of the digestive tract accentuating dysmicrobism and promoting complications. Moreover, pathogens in the oral cavity can colonize the lung and lead to postoperative pneumonia with increased morbidity and mortality [ 30 ]. Until the patient is able to exercise basic hygiene, the task must be performed systematically by the medical personnel.

Pain therapy. Pain is one of the main factors that can delay the recovery of the operated patient. Pain delays the patient’s mobilization, limits the range of motion of the diaphragm, delays the resumption of intestinal transit, and psychologically stresses the patient. Postoperative pain therapy begins during surgery, avoiding excessive traction, tension in the sutures or unjustified extensive dissections outside anatomic planes. From this point of view, laparoscopic surgery and generally mini-invasive surgery, whenever possible, brings major advantages. Also, a very important role in combating pain is the positioning of the patient in bed after surgery. The patient should be positioned as comfortably as possible, avoiding tension on the muscles around the incision areas. The movement of the patient in bed after surgery should not be forbidden; on the contrary the patient should be encouraged to adopt the position in which the pain is minimal and to change his/her position periodically. Beds with semi-rigid elastic mattresses are preferable, which can provide the patient with effective support to achieve active movements and which evenly distribute the patient’s weight.

The abdomen should be examined at least twice a day. In the first 24 hours after surgery, the patient may complain of low to moderate pain in the abdomen, accentuated by active movements or coughing. The pain must be combated accordingly, in order to avoid the development of the “fear” of mobilization. Pain therapy must be adjusted to the extent of surgery and known mechanisms of pain. Multimodal postoperative analgesia appears to provide better outcomes [ 31 ]. Usually, the combination of acetaminophen with a non-steroidal anti-inflammatory drug is sufficient for most patients, but in some cases, local analgesia [ 32 ], or even patient-controlled epidural analgesia may be needed. In case of prolonged use of non-steroidal anti-inflammatory drugs (NSAID), prophylaxis of gastroduodenal disorders like erosions, hemorrhage or ulcers should be considered, especially if the patient’s oral feeding has been temporarily suspended. In those cases, proton pump inhibitors and E-prostaglandin analogs seem to be the most effective, then the histamine receptors antagonists, while barrier agents are mostly useless since they do not interfere with the pathogeny of NSAID-induced ulcer. However, proton pump inhibitors are to be diverted in patients with a current or recent history of antibiotherapy, since the two conditions act synergically favouring severe Clostridium difficile colitis [ 33 ]. The use of major opioid analgesics is not indicated because it contributes to the accentuation of intestinal paresis and favors the accumulation of tracheobronchial secretions [ 34 ]. There are combinations of painkillers (analgesics) that combine a non-steroidal anti-inflammatory and an opioid in low concentrations where the side effects are absent or negligible. In the context of intense pain that does not yield to milder painkillers, it is recommended to place an epidural catheter to ensure the effective analgesia administration with minimal effects on the intestinal smooth muscles [ 35 , 36 ].

The inspection of the abdomen helps in monitoring the degree of distension of the abdomen due to the accumulation of gases and fluids in the digestive tract lumen. This condition is mainly caused by the absence of peristalsis but also by the change of microbiome. Postoperative paresis, present after interventions involving or exposing the intestinal loops, must be actively prevented. Prevention can and should begin in the preoperative period and continue in the operating room and beyond. The very important measures are related to the optimum hydration and correction of the electrolyte imbalances. Because - Enhanced Recovery After Surgery - (ERAS) protocols have been progressively adopted, the patient is usually advised to avoid starving in the preoperative period and to have a light liquid diet in the evening, before scheduled operation. Clear fluid diet is allowed up to 2 hours preoperatively [ 37 ]. Specific medications – prokinetics - like anticholinesterases and parasympathomimetics may be prescribed in order to stimulate peristalsis [ 38 ]. Neostigmine, a synthetic anticholinesterase alkaloid, stimulates intestinal peristalsis with less extensive side effects on the cardiovascular and respiratory systems [ 39 ]. Local-acting intestinal peristaltic stimulants, such as castor oil may be administered orally or introduced through the nasogastric tube (NGT). Prolonged paresis requires the placement of an NG-tube for decompression of the digestive tract, prevention of vomiting and airway aspiration or Mendelson’s syndrome. We do not usually use nasogastric decompression tube, but only in emergency surgery and just in cases associated with high fluid and gas distension or in cases with expected prolonged ileus [ 40 ].

Various methods of reducing postoperative ileus have been studied. It seems that something as simple as abdominal massage after colonic surgery can reduce the postoperative pain and help resume intestinal transit [ 41 ]. Similarly, numerous studies including a metanalysis advocate for the use of chewing gum in order to reduce the ileus period [ 42 ] but the results have been contradicted by other studies [ 43 ]. Chewing gum is adopted by the Enhanced Recovery After Surgery (ERAS) protocols as a measure that could reduce ileus [ 37 ]; we recommend its selective use whenever applicable.

Commonly used opioids such as morphine and fentanyl can prolong the postoperative ileus, by acting like agonists on mu receptors; it is recommended to reduce their use at least in the postoperative settings. In contrast, some kappa agonists like fedotozine U-50, 488H, bremazocine or asimadoline appear to reduce ileus in animal models studies but have never entered clinical practice [ 44 , 45 ].

For the lower digestive tract surgery, the placement of a transanal gas tube may be used, in order to evacuate the increased pressures that may develop at this level [ 46 ]. The procedure is safe and very effective especially in low rectal anastomosis [ 47 ]. The transanal tube (TAT), usually 28–30 CH (Charrierre), is placed at the end of the procedure foiled in greased gauze and is primarily used for intraoperative leakage test. The tube is usually left in place for 48 hours or more, accordingly to the patient evolution. The TAT seems to reduce anastomotic leakage (AL), the need for re-interventions for AL, and it is proposed by some authors for the reduction of defunctioning stoma [ 48 ]. After interventions that do not involve the colon, an evacuation enema may be performed at 2–3 days postoperatively; this reduces stasis and microbial load at this level, and stimulate the resumption of normal peristalsis.

Close patient surveillance with abdominal palpation is required in order to take and adapt the appropriate postoperative measures. Palpation aims to detect possible areas of deep tenderness and infiltration in the abdomen, painful areas in which any discrete signs of peritoneal irritation draw attention to the occurrence of a complication. The jerky palpation may show flapping, a sign with great specificity for postoperative occlusive syndrome, especially when the patient has initially resumed intestinal transit. Percussion highlights diffuse tympanism during intestinal paresis, while persistent localized hypersonority in an area after hesitant resumption of intestinal transit may draw attention to a complication that may have developed at this level. Auscultating the abdomen can reveal a silent abdomen during the paretic period or vice versa- vivid noises, accompanied by whistling and crackling, an expression of the “struggle” of a loop to overcome a distal obstacle/obstruction. Anastomotic leakage is the most feared complication because it comes with significant morbidity and mortality in short but also in long term [ 49 ]. The earlier the recognition of an anastomotic leakage the better and prompter measures can be taken in order to limit or avoid major morbidity [ 50 ]. Postoperative peritonitis following an anastomotic leakage usually develops quietly and may remain undetected since the patient is on pain-killers and the peritoneal surface is less reactive after surgical aggression. CT scan can be falsely negative for anastomotic leakage in fairly large number of cases, therefore, in such cases, it is advisable to take action on first clinical signs of peritonism [ 51 ]. Measures may include various combinations of relaparotomy, percutaneous drainage, postoperative wound opening, antibiotics and complete parenteral nutrition. Earlier detection of the underlying pathology result in prompt intervention and therefore better outcomes [ 52 ]. In cases of diffuse peritonitis, relaparotomy is mandatory to remove the peritoneal contamination and try to gain control of its source. There is no ideal solution for controlling anastomotic leakage. In some cases, re-resection and anastomotic reconstruction can be an option depending on the local and general conditions. In some cases, the anastomosis may be suppressed, followed by closure of the distal end, while the proximal partner is exteriorized in a stoma. This seems to be the safest approach but it is not always feasible. In other cases, perianastomotic drainage might be enough [ 53 ], but usually a proximal diverting stoma is advisable in addition to local drainage. The decision is highly dependent on the surgeon’s experience who should always thoroughly evaluate the local and general condition of the patient; it also depends on ICU level, and the local feasibility of endoscopic stenting, interventional radiology, and other interventions.

Some cases may be managed conservatively with the main purpose being to transform the leak into an isolated enterocutaneous fistula [ 53 ]. Adequate drainage of the leak results in reduction of the general and local signs of sepsis and inflammation with resuming of intestinal transit, tolerance to dietary intake and improvement of the general condition of the patient. The use of a low-pressure drainage system [ 54 ] can help organize the fistular tract, avoiding extensive contamination or digestion (by the activated intestinal enzymes) of neighboring tissues. For the success of this method, we need to ensure that the lumen of the tube remains patent and the surrounding tissues are not being sucked into the holes of the draining tube. The normal evolution of the fistula is with progressive reduction of the flow (which must be noted every 24 hours). In 5–7 days after fistular organization (clinically documented and by contrast enhanced imaging) and the reduction of the flow, we can progressively mobilize the drain by 2 cm every 2–3 days. This allows the tissues to collapse and close the fistula. Sudden reduction of a fistula flow or the early and fast suppression (in a single gesture, not progressively mobilized) of a tube that drains the leak, can result in local abscess formation or even peritonitis. Usually, the fistula closes in 2–3 weeks for the colon and 1–3 month for the small bowel but the time is variable depending on the various factors like type of surgery, age, general performance status, nutrition, level of anastomosis and partners of anastomosis quality [ 55 ], but most importantly dependent on the functional status of the bowel. If there are no anatomic (adherences or strictures for instance) or functional obstacles (residual abscess, Crohn disease, etc.) distally, the fistula closure will be faster. Insufficient drainage of the fistula or abdominal sepsis will result in persistence of local inflammation with secondary impairment of the peristaltic movements, creating a vicious circle that will delay fistula closure.

7. Postoperative wound surveillance

The postoperative wound should be closely monitored on daily basis. In the immediate postoperative period, a sterile dressing covers the wound so we may not be able to directly inspect the sutures. In the first postoperative hours soaking of the dressing [ 56 ] with blood is the main sign to look for. The presence of the blood prompts the physician to look for a source of bleeding at the superficial or deeper level and perform adequate hemostasis. In most cases, it is a low-flow bleeding from a dermal vessel that can be controlled by as simple as a local pressure dressing, placing a mesh with hydrogen peroxide, fibrin glue, or a supplementary stitch under local analgesia. This may also have psychological consequences on the patient since the psychological impact of the presence of blood in sight of the patient may induce a state of anxiety and agitation. For deeper bleedings that tend to form hematomas between the wound layers or margins, the evacuation of cloths is mandatory otherwise impairing wound healing. We should not forget that digestive surgery is a contaminated one, because of the breach of gut mucosa, and that blood is the ideal culture medium for bacteria. Therefore, leaving a dead space filled with a hematoma between the margins of the postoperative wound is equivalent with initiating a germ culture. Left in place, in the following days, the cloth will become a more or less profound abscess. At this moment, even if we drain it, the damage has happened already, and short-term morbidity as well as long-term (such as incisional hernia) increase. In order to avoid those unfavorable outcomes, the most appropriate action seems to be the immediate opening of the postoperative wound, (more or less extensive, but usually 2–4 stitches in the area of the bleeding), evacuating the hematoma under sterile conditions, lavage of the wound with antiseptic solutions, targeted hemostasis and primary closure. If there is doubt on definitive hemostasis or sterility conditions the wound can be left open, covered with sterile dressing until granulation is obtained and secondary superficial suture can be accomplished.

Sometimes under the blood-soaked dressing, we may find a diffuse bleeding, accompanied by an ecchymotic aspect of the wound edges aspects that usually indicates poor coagulation. In this context, we must not forget that the superficial operative wound is a mirror of what is happening in depth, in the operative site, and the general measures for restoring the coagulation balance must be prompt and vigorous. Of course, an ecchymosis of the postoperative wound may seem a benign and maybe minor to negligible complication requiring no action or simply a bag of ice, but if the same happens at the level of the anastomosis deep in the abdomen, anastomotic leakage becomes plausible. In this context, we immediately adjust the anticoagulation treatment, postponing or even skipping a dose until we further investigate coagulation status of the patient. As long as the anticoagulation therapy is suspended, it is advisable to use alternative methods to prevent DVT in lower limbs such as intermittent compressive therapy [ 57 , 58 ] or at least compressive stockings.

In the following days, the normal surgical wound is usually uncovered, “in plain sight” or “exposed to the air”. There is no reason for covering with sterile dressing since the wound is already sealed by the fibrin that is organized between the two edges. Usually, this normal wound sealing process takes 24–48 hr. in clean or clean-contaminated wounds. Even if there is no strong evidence or consensus [ 54 , 56 ] on how long we should keep a sterile dressing, our current practice is to avoid dressing after 48 hr. The zonal erythema of the wound accompanied by a localized swelling, possibly centered on a slightly ecchymotic area, suggests the development of the suppurative complication. In this context, the wound must be explored with a stylus or a fine forceps inserted relatively easily in the respective area. The evacuation of a seroma or hematoma that has already turned purulent will prompt the removal of several stitches, with wide opening of the wound, followed by mechanical and antiseptic debridement [ 56 ]. Insufficient opening of the wound without adequate drainage will perpetuate the infection and allow the infection to spread to new spaces in the vicinity of the wound. In such instances a superficial infection can become profound and healing may be delayed and deficient, with wound granulomas, postoperative incisional hernias or even eviscerations. Of course, in extensive surgical site infections, local measures must be accompanied by systemic antibiotic therapy, initially with large spectrum according to the most plausible germs and then targeted when culture results become available [ 10 , 56 ].

8. Postoperative drainage monitoring

Drainage is one of the fundamental means of treatment and prophylaxis in general surgery. Intraoperatively, drainage can be established in various areas of the peritoneal or pleural cavity (in the case of interventions involving the opening of the pleura), at the level of segments of the digestive tract (stomach, intestine, bile ducts) or in remaining cavities following the evacuation of pathological processes (abscesses, hydatid cysts, on the soft parts after evacuation of abscesses, hematomas, tumors, etc.).

8.1 Drainages of the peritoneal cavity

They are usually placed after medium or major and contaminated abdominal surgical interventions that open the peritoneum. That said, there is no consensus in the literature around the need for drain(s) placement after abdominal surgeries [ 59 , 60 , 61 ]. It is advisable to use drains only when and where they are justified. Drains are then removed in due time after they have served their purposes [ 62 ].

In the first hours after surgery, peritoneal drains usually produce small amounts of serosanguinous fluid. Pure blood drainage usually indicates a hemostasis defect that can be minor in small vessels, often secondary to clotting disorders, or major by slipping of ligatures placed on relatively large vessels. Under these conditions, it is extremely important that the drainage be interpreted in the clinical context of the patient, the association with a hemodynamic instability raising the problem of an immediate reintervention to complete the hemostasis. It is advisable to check the condition of the drain tube and especially its permeability frequently, as it can be clogged with clotted blood [ 63 ]. In this case, the tube remains unproductive, “hidden” under a clean dressing on the surface, thus providing a false sense of surgical reassurance. Unclogging of the drain tube leads to the resumption of blood flow. If the hemorrhage is still active, the drainage will be with reddish coagulable blood, drop by drop, and will be a strong indication for relaparotomy or laparoscopy [ 64 ]. In some cases, not uncommonly, the source of bleeding can be identified in the parietal trajectory of the drainage tube that intercepted a more or less important blood vessel. Local anesthesia and targeted hemostasis can save the patient from an unnecessary laparotomy. Sometimes the drainage resumes with blackish, incoagulable blood, mixed with small partially lysed cloths. This aspect of drainage, which usually persists for several days, sometimes up to weeks, indicates the progressive evacuation of a clot or a large hematoma. Particular attention must be paid in these situations to dressing maneuvers as they can lead to germ contamination and the transformation of the hematoma into an abscess.

The normal evolution of the drainage in the following days is towards the diminution and progressive clearing up. This is the optimal moment to remove the drain. When the drainage is supposed to “protect” an anastomosis we remove the tube after 5–7 days, once the anastomosis has passed the critical period and the intestinal transit is resumed [ 60 ]. The tube does not prevent anastomotic dehiscence but may avoid relaparotomy to control an anastomotic dehiscence. If the drainage is to be maintained for a longer period, it is recommended to mobilize the tubes after several days, with their dislocation from the fibrin deposits that form around, a condition for the drainage to remain effective and to prevent pressure lesions that the tube can determine on certain structures such veins, nerves, ureters, etc.

Persistence of significant drainage, over 500 mL/24 hr. (sometimes 3 L/24 hr), with serous fluid, denotes ascites production, secondary to an advanced malignancy (ovarian, peritoneal or massive hepatic metastases), liver cirrhosis or associated hypoproteinemia. Most often these conditions are suspected based on preoperative work-up and then well-documented by the intraoperative exploration. Few recent studies advise to avoid drainage in cirrhotic patients after abdominal surgery [ 65 , 66 ]. If drainage is necessary, the same studies recommend discontinuing them as soon as possible. When suppressing the drain tube in these cases, a parietal restraint suture is often required to control the discharge of ascites that will otherwise persist through the parietal path of the tube. However, surgical suture dehiscence is frequent in such patients accounting between 20 and 45% [ 66 ], forced by the pressure exerted by the fluid and favored by hypoproteinemia and dysmetabolism. In those patients, we use a controlled-flow drainage tube or an abdominal decompression catheter left intraperitoneally until the wound is well healed and/or ascites production is therapeutically reduced. This management allow a controlled drainage of the ascites, in a closed system avoiding the infectious risk. Otherwise, if the tube is removed too early, intraabdominal pressure of the ascitic fluid will force the wound dehiscence and will leak uncontrollably.

After interventions involving an extended lymph node dissection, the initial drainage with serosanguinous appearance becomes sero-citrine after 2–3 days, but persistent, sometimes at flows between 50 and 300 ml / 24 h, consisting of lymph fluid rich in protein. Since there is not a consensus [ 67 ] our practice is to keep the tube in position until a significant decrease in the amount drained, otherwise there is a risk of developing lymphatic collections [ 68 ] (lymphocele), which can become secondarily infected.

Under the conditions of perianastomotic drainage, the resumption of a bloody drainage, cherry colored with low flow, sometimes gray to frank purulent with specific odor, associated or following a febrile episode is most often the sign of the onset of an anastomotic fistula. This moment usually coincides with the recurrence of the intestinal paresis, the alteration of the general condition of the patient, the increase of the digestive aspirate or vomiting. Muscle guarding may be present but the specific contracture of peritonitis is most often missing. Postoperatively, most signs of peritonism are less pronounced [ 69 ], especially in the elderly patients. Abdominal examination usually reveals localized but difficult to delineate tenderness, accompanied by a local dull pain which is accentuated on palpation. Frequently associated is the suppuration of the surgical wound that must be monitored and opened as early and as wide as needed, a unique gesture that has the ability to limit the extensive evolution in depth. Over the next few days, digestive content according to the level at which the anastomosis was performed, will be evacuated on the drain tube or directly through the surgical wound. Under the conditions of a favorable evolution, the drainage tube will be the “splint” on which an entero-cutaneous fistula forms, the inflammation then gradually decreases, the patient becomes afebrile, resumes his intestinal transit, tolerates diet, and the abdominal signs gradually subside. The development of signs of generalized peritonitis with the persistence of fever and the progressive alteration of the general condition means an insufficient drainage of the anastomotic dehiscence defining a grade C leakage [ 70 ] and forces to reintervention. Prompt diagnosis is the key for better outcomes and in this respect the CT exam seems to offer the best diagnostic chances [ 69 ]. Either conservative or interventional management is applied, in such conditions addition of antibiotherapy in curative course and a non-steroidal anti-inflammatory drug is always necessary.

8.2 The drainages of some segments of the digestive tract

The drainages of some segments of the digestive tract are generally established intraoperatively and aim at achieving temporary decompression of the organs they drain (stomach, common bile duct, etc.) As mentioned, their main role is to evacuate the secretions accumulated in the conditions of postoperative paresis and fight against intraluminal hyper pressures. The most common form is represented by the upper digestive aspiration through a nasogastric tube (NGT), in which the probe inserted trans-nasally and is conducted intraoperatively at the level of the drained segment - esophagus, stomach, duodenum, small intestine. In general, the probe is placed in the conditions of performing anastomoses or sutures at the level of these segments having as main role the protection of the suture. ( anastomotic dehiscence prophylaxis role ). The quality and quantity of the digestive aspirate must be systematically monitored and interpreted in the context of the general and local examination of the abdomen ( diagnostic tool role ). Occasionally the tube can be used to administer medications, to perform lavage or even enteral nutrition ( therapeutic role ) [ 71 ]. Congruently with literature reviews we do not systematically use the nasogastric tube [ 72 ] but only in cases with stasis, intense paresis or expected impaired temporary deglutition.

The normal evolution of the aspirate is towards “clarification” and progressive decrease in the context of the resumption of the intestinal transit and the reduction of the abdominal distension, aspects that mark the optimal moment of NGT suppression. The sudden decrease of the aspirate with the persistence or the accentuation of the distension denotes the clogging of the tube and the need to re-permeabilize it. It should not be forgotten that a significant amount of electrolytes is lost in the aspirated fluid, a loss that must be compensated by intravenous perfusion, correlated with the serum ionogram and the quality and quantity of the aspirate. Fluid loss through nasogastric tube must also be compensated by parenteral intake.

In some cases, the drainage of specific segments can be realized by tubes that are trans-parietally externalized, such as duodenostomies or jejunostomies. In the first 2–3 days postoperatively the main role of the tube is to decompress the bowel segments that they drain. The “prototype” for this use is lateral duodenostomy after total gastrectomy with “Roux en-Y” esojejunal anastomosis, in which the duodenum is partially excluded from digestive transit. After normal peristalsis resumption announced by the decreasing of the fluid output per tube over 24 hr., the drainage tube placed laterally in the duodenum can be used as a temporary feeding path [ 73 ] until the esojejunal anastomosis can support oral feeding. Although considered a “forgotten” method [ 73 , 74 , 75 ], the use of lateral duodenostomy gave us satisfaction (yet unpublished data), being the path that we use in order to achieve early enteral feeding, one of the main goals of ERAS protocol, especially in doubtful anastomosis or documented leakage.

External biliary drainage aims at decompressing the intra- and extrahepatic bile ducts after CBD exploration in the presence of a distal obstruction, or to obtain a controlled biliary fistula after major hydatid cyst resections or major hepatectomies [ 76 ]. The most common use is the “Kehr” drain with a “T” tube placed in the common bile duct (CBD) which will be suppressed in a controlled manner after resolving the distal obstruction or the proximal leakage. The indications for T tube decreased in the era of endoscopic retrograde colangio-pancreatography (ERCP), endoscopic drainage and stenting, etc. However, there are specific situations when the T tube remains a very good option. Usually the T tube is “guarded” by a subhepatic intraperitoneal drainage that in the first days after surgery will take over small amounts of bile that may leak around the T tube. In the following days the quantity and quality of bile drained by the T tube will be attentively monitored. Normal drainage should be clear bile with a flow of 3-400 ml/24 h and progressively decreasing. The persistence of a high flow clear yellow bile that sometimes can reach 1.5 l/day is a clear indication that the liver functions normally but the common bile duct is still obstructed. In those situations, the T tube becomes also a diagnostic tool, since it allows a rapid cholangiography that in most cases will clarify the diagnostic. Bile drainage containing floaters and deposits that persists for a few days raises the suspicions for intrahepatic acute cholangitis. In those cases, the T tube offers the possibility to collect seriated bile samples for bacteriology exam, culture and antibiogram, allowing thus a specific targeted antibiotherapy. In case that the drainage flow is low with a translucid uncolored fluid hepatic insufficiency should be suspected. Without becoming exhaustive in approaching an extremely complex subject, it should be mentioned that in conditions of abundant biliary drainage that persists for long periods, the imbalances induced in the body become major both by the complex loss of electrolytes, salts and bile acids but also by insufficient nutrient absorption from the digestive tract, generated by insufficient digestion. In such conditions, the reintroduction of the drained bile into the digestive tract by oral administration, via the naso-gastric tube or jejunostomy, should be considered especially in critical ill patients that do not support an internal diversion of the bile flow.

8.3 The drainage of residual cavities

The drainage of residual cavities after the evacuation of some pathological processes is generally a drainage with a long maintenance period (sometimes 1–2 month or more), time necessary for the repair processes to progressively reduce and eliminate the cavities (ex: infected hydatid cyst of the liver, pancreatic or peripancreatic abscess, etc.). The quality and quantity of drainage will be constantly monitored. Periodically the drain tube will be mobilized with dislocation of 1–2 cm in order to prevent its “anchoring” in the repair tissue, decubitus injuries on adjacent organs or structures, as well as to allow the progressive reduction of the depth of the cavity. If the drained process was a septic one, it is advisable to change periodically the drain tube since the germs tend to form biofilms on them. The profound tip of the drain will be sent for bacteriologic exam and cultures.

8.4 Drainage of the pleural cavity

Drainage of the pleural cavity is used after openings of the pleura, usually during esophageal interventions, a situation in which the drain is placed intraoperatively after re-expansion of the lung. The simplest drainage is with a transthoracic tube conducted in a half-loaded vessel with sterile saline solution, below the liquid level, to prevent pneumothorax. Mobile kits with unidirectional valves are available and considered better because they facilitate an easier and early mobilization of the patient. Normal drainage in the first days is serous, perhaps with a light serosanguinous color but with a low output, usually under 200 ml/24 h. Higher flows are reported after extended lymph node dissection (performed for esophageal carcinomas) or important bleeding [ 77 ]. The production of the bubbling phenomenon in the bottle usually denotes the existence of a “valve” through which air enters the pleural cavity - damage to the lung parenchyma or tracheobronchial-pleural fistula, another unrecognized pleural lesion (rupture), or lack of tightness of the drain tube in the parietal tract. If the intraoperative pleural lesions remain unrecognized, a situation sometimes encountered during at the esogastric junction interventions, especially in interventions for large hiatal hernias, postoperative dyspnea will require immediate clinical examination and chest X-ray which will evidence pneumothorax. In those cases, a pleural drain will be instituted under local analgesia. Pleural drainage will be removed when it becomes unproductive for gases and fluids and control X-ray will show normal pulmonary expansion, usually 5–10 days after surgery. During the removing maneuver the tube will be closed with a forceps and the parietal route will be closed with a suture and tight dressing for 24 h in order to avoid air aspiration in pleural cavity.

9. Postoperative nutrition

The postoperative diet should be strictly individualized. Current protocols recommend resuming oral feeding as early as possible [ 10 , 37 ]. In conjunction with minimally invasive surgery, less aggressive anesthesia with reduced side effects, patient mobilization as early as possible, multimodal analgesia, all of which are part of the ERAS (enhanced recovery after surgery) protocol or fast track surgery.

Postoperatively, oral feeding is usually resumed progressively, starting with fluids, sometimes even from the day of surgery. Fluids can initially be administered in small amounts of “testing” of tolerance. The quantities of ingested fluids can then be increased even in the presence of the digestive tract high anastomosis [ 78 ]. In addition to the cleansing effect of the digestive tract, the dilution of toxic products and digestive enzymes, there is a proven trophic effect on the digestive mucosa, especially for glucose rich fluids, which strongly support this type of approach. The resumption of normal peristaltic and intestinal transit for gas usually marks the moment when we switch to a semi-solid diet based on vegetable purees, cheese, eggs, etc., which gradually begin to bring protein capital to the organism. Meat based products are introduced in the diet usually 2–3 days postoperatively using easy to digest white meat like fish and poultry. In the immediate postoperative period we avoid uncooked food, especially raw fruits and vegetables since their fermentative potential and fiber content that make hem harder to digest and can cause distension. After transit resuming, a banana can be daily eaten for its potassium content and then small amounts of other fruits, but always taken during the meal.

Given that in some cases the enteral diet is impractical (ex: esophageal anastomosis dehiscence) the complex products of amino acids, lipids and vitamins will be added in parenteral nutrition. Because large amounts are required it is preferably to administer them on a central venous catheter. However, it should be noted that this type of nutrition can replace the normal oral diet only for a limited time. For patients who expect a long period of oral nutrition suspension, it is preferable to perform a feeding jejunostomy [ 79 ].

10. Postoperative antibiotic therapy

Postoperative antibiotic therapy is reserved for pathologies involving extensive infections, stray patients with major interventions involving prolonged septic time, soft tissue infections, associated urinary tract infections, infectious pneumonia or another well-documented infectious syndrome.

Prolonged postoperative “so-called prophylaxis” antibiotic therapy has no justification in another context [ 80 ]. It brings major disadvantages by selecting resistant bacteria, altering the normal intestinal flora, the strain of liver and/or kidney function. In localized infections as well as in wound suppurations, the healing process starts with the appropriate drainage and not the antibiotic therapy that will be useful but to limit extensive infections and prevent dissemination. In these situations, the antibiotic therapy will be initiated according to the clinical suspected pathogen and the bacteriological profile of the nosocomial infections in the respective service, and modified according to the antibiogram after culture results are available [ 56 ].

11. Prevention of deep vein thrombosis and pulmonary thromboembolism

To this end, anticoagulant therapy is usually started preoperatively with very broad indications for interventions exceeding 30 minutes, knowing that a large number of thrombotic events in the venous system of the lower limbs begin during surgery [ 81 ]. Fractionated (or low molecular weight - LMWH) heparins as well as low dose unfractioned heparin are currently used [ 82 ]. Anticoagulant therapy is continued postoperatively for several days after the patient’s usual mobilization, sometimes up to 3 weeks depending on the risks. After this period, as appropriate, anticoagulant therapy with HGMM will be replaced with oral anticoagulants - acenocoumarin derivatives, novel oral anticoagulants (NOACs) or antiaggregants. For each aspects of the anticoagulation therapy (when to start, which type, what dose, for how long, etc.) there are numerous predictive scores and tables, mostly used being the PADUA Score [ 83 ] and the Caprini Score.

In at risk patients, the calves should be inspected and palpated at least once a day. Immobilized patients are encouraged to perform active exercises in bed until complete mobilization. The appearance of a seemingly unjustified swelling or leg pain, a discrete unilateral edema of the leg, sometimes with a positive Homans sign (pain at the dorsiflexion of the foot) requires a Doppler ultrasound of the venous system of the lower limbs and the transition from prophylactic doses of anticoagulant to curative doses.

In patients with coagulation defects, with severe anemia (such as a gastrointestinal bleeding) often associated with coagulation disorders, in patients with unresectable gastrointestinal neoplasms, in polytraumatized patients with extensive hematomas at various levels or whenever heparin administration is considered risky, compressive therapy is recommended [ 84 ]. Compressive therapy can be passive, using pressure stockings, but desirable active using an intermittent compression system of the lower limbs, equipped with pneumatic cuffs that are progressively inflated and decompressed automatically, with computerized control of pressure and application times.

12. Prevention of bedsores and patient mobilization

The development of bedsores is an undesirable event that significantly influences the patient’s recovery with increasing morbidity, hospitalization, medication consumption, time and resources. Elderly, deproteinized patients, diabetics, stroke patients, patients with urinary or fecal incontinence, patients with fractures or immobilized for a long time are susceptible to the development of bedsores [ 85 ]. Whenever we treat such patients, we must take into account those risk factors for an early application of bedsores prophylaxis. The most common areas affected by the development of bedsores are the sacral region, buttocks, trochanters and shoulder blades. Prophylaxis includes intermittent inflated mattresses that periodically change the pressure on the support areas, powdering of wet areas, passive mobilization for immobilized patients. They are passively transferred to alternative positions (left lateral decubitus, right lateral, dorsal, ventral) at the shortest possible time intervals (2–3 hours) after a schedule established and strictly observed. The pressure areas must be massaged to promote the opening of blood circulation in the area.

Postoperative mobilization as early as possible is an extremely important factor in the patient’s recovery since it promotes the resumption of intestinal motility, reduces the risk of decubitus pneumonia and postoperative pneumonia by promoting normal respiratory dynamics, requires and stimulates the adaptation of the cardiovascular system, reduces the risk of deep vein thrombosis and thromboembolic events, prevents the appearance and development of bedsores. Thus, the patient must be passively mobilized on the edge of the bed from the first postoperative day and encouraged to repeat the maneuver several times during the day. The next day the patient will be accompanied for a few steps in the room and will later become independent at distances of 20–50 m. Of course, this mobilization program will have to be adapted to each case depending on the particularities (age, type of surgery, comorbidities, etc).

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Chapter 3-1:  Approach to the Patient with Abdominal Pain - Case 1

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Chief complaint, constructing a differential diagnosis.

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Mr. C is a 22-year-old man who complains of diffuse abdominal pain.

Figure 3-1.

The differential diagnosis of abdominal pain by location.

Abdominal pain is the most common cause for hospital admission in the United States. Diagnoses range from benign entities (eg, irritable bowel syndrome [IBS]) to life-threatening diseases (eg, ruptured abdominal aortic aneurysms [AAAs]). The first pivotal step in diagnosing abdominal pain is to identify the location of the pain. The differential diagnosis can then be limited to a subset of conditions that cause pain in that particular quadrant of the abdomen ( Figure 3-1 ).

Several other pivotal points can help narrow the differential diagnosis including (1) the time course of the pain, (2) peritoneal findings on exam, (3) unexplained hypotension, and (4) abdominal distention. Each of these is reviewed below.

The time course of the pain is a pivotal feature. Some diseases present subacutely/chronically over weeks to months or years (eg, IBS) whereas others present acutely, within hours to days of onset (eg, appendicitis). In patients with their first episode of acute severe abdominal pain, a variety of life-threatening, must not miss diagnoses must be considered (eg, AAA). Many of these diseases that cause acute abdominal pain cannot recur because patients are either treated or die of complications (eg, AAA, acute appendicitis, splenic rupture.) Since prior episodes are incompatible with many of these diagnoses, a history of such prior episodes narrows the differential diagnosis. Therefore, the differential diagnosis of abdominal pain can be organized based on whether patients are presenting with their (1) first episode of acute abdominal pain, (2) a recurrent episode of acute abdominal pain, or (3) chronic/subacute abdominal pain. Table 3-1 outlines the typical time course associated with different diseases causing abdominal pain. See Table 3-2 for a summary of abdominal pain organized by location, time course, and clinical clues.

AAA, abdominal aortic aneurysm; DKA, diabetic ketoacidosis; IBD, inflammatory bowel disease; IBS, irritable bowel syndrome; PID, pelvic inflammatory disease; PUD, peptic ulcer disease.

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Center for Bloodless Medicine and Surgery

Case study: vascular surgery, case study 1:, revision surgery for thoracic and abdominal aortic aneurysm using a minimally invasive endovascular fenestrated stent graft.

An 81-year old female patient (Jehovah’s Witness) presented with an expanding aortic aneurysm in the thoraco-abdominal (chest and abdomen) region that had enlarged from 5 to 7 centimeters.

The patient’s prior endovascular aortic aneurysm stent graft repair in the infra-renal portion of the abdominal aorta made the current aneurysm repair substantially more challenging. Since she is a Jehovah’s Witness and does not accept blood transfusions, it was decided that an open surgical approach was not an option due to the high risk of bleeding. A minimally invasive, endovascular repair was chosen as the ideal treatment method since the expected blood loss is decreased dramatically compared to traditional open aortic surgery.

The surgery was performed by one of our most experienced vascular surgeons, Dr. James Black, and took place over the course of 7 hours. The anesthesia care was provided by Dr. Steven Frank, the Director of the Center for Bloodless Medicine and Surgery at Johns Hopkins. The spinal drain performed nicely and the patient’s blood pressure was maintained above the threshold necessary to ensure blood flow to the kidneys and the spinal cord. Total blood loss was 300 ml (about 6% of total blood volume). The majority of the blood lost was returned to the patient using autologous blood salvage (Cell Saver). This option had been discussed with the patient, and she agreed to its use.  She awoke from the surgery with normal movement in both arms and both legs.

The patient’s preoperative hemoglobin was 11.3 and the postoperative hemoglobin was 9.6, well within the margin of safety. Her postoperative course included 5 days of erythropoietin, intravenous iron, B12, and folate, a regimen recommended by our Bloodless team Hematology consultant, Dr. Linda Resar, in order to stimulate the bone marrow to produce red blood cells. After a few days of physical therapy, she was able to walk on her own and she was discharged from the hospital after an 8-day stay. Since discharge, she has not experienced any further problems, and has not needed to return.

Case Study 2:

Ascending aortic aneurysm dissection repair with cardiopulmonary bypass and deep hypothermic circulatory arrest.

Blood conservation methods:

• EPO, IV iron, B12, Folic acid
• Intraoperative autologous normovolemic hemodilution (IANH)
• Retrograde autologous prime (RAP)
• Modified ultrafiltration
• Anti-fibrinolytic medication - Epsilon-aminocaproic acid (Amicar)
• Thromboelastography
• Minor fractions (cryoprecipitate and prothrombin complex concentrate (PCC)

A 37-year old male Jehovah’s Witness patient was transferred from an outside hospital to Johns Hopkins with a dissecting ascending aortic aneurysm. He presented with chest pain and a 15-cm aortic dissection diagnosed by CT scan. Given his history of prior cardiac surgery (aortic valve replacement), his aneurysm repair would require a “redo sternotomy” which is associated with substantially more blood loss than a first time surgery into the chest. He was treated with nitroprusside, a potent vasodilator, as well as other anti-hypertensive medications (Labetalol, Amlodipine) to keep his blood pressure down to avoid what might have been a catastrophic rupture of the aneurysm.

We elected to give him erythropoietin (EPO) 30,000 units/day, intravenous iron sucrose 200 mg/day, vitamin B12, and folic acid over a 1-week period, in order to increase his hemoglobin level prior to surgery from 12.7 to 13.7 g/dL.  Given the challenging nature of the surgical procedure he required, we had to weigh the risk of aneurysm rupture vs. the risk of anemia, in choosing to wait on scheduling the surgery. Based on calculations of his red cell mass, our Bloodless Team Hematology consultant (Dr. Linda Resar) and his cardiac surgeon (Dr. Ashish Shah) made the decision to achieve a target hemoglobin close to 14 g/dL before attempting the surgery.

The intraoperative course went smoothly. A cardiac anesthesia team experienced with Jehovah’s Witness patients, led by Dr. Charles Brown, was assigned to provide the intraoperative care. A team of Perfusionists with Jehovah’s Witness experience (Larry Wolf and AnnMarie Fatula), were also assigned to the case. First 2 units of autologous blood were removed while maintaining a continuous connection to the patient. Intraoperative autologous normovolemic hemodilution (IANH) was then accomplished by giving volume expanders (albumin and crystalloids). Full cardiopulmonary bypass with retrograde autologous priming (RAP) was initiated using a “fem-fem” approach (femoral vein to femoral artery), which allowed us to avoid placing cannulas into the ascending aorta. The patient was cooled on cardiopulmonary bypass to 18 °C (about 10 °C lower temperature than the typical cardiac surgery case), in order to induce deep hypothermic circulatory arrest.  This allowed the ascending aortic repair and a brief period (35 minutes) of total interruption of blood flow to the brain, which was required to complete the distal aortic anastomosis. The patient was then aggressively rewarmed to avoid bleeding from residual hypothermia during the postoperative period. During cardiopulmonary bypass, a hemoconcentrator (modified ultrafiltration) was used in order to provide concentrated whole blood for the patient and to minimize blood lost to the cardiopulmonary bypass circuit. Autologous blood salvage (the Cell Saver) was also used to return as much blood as possible to the patient from the bypass circuit. Epsilon-aminocaproic acid (Amicar) was used as an anti-fibrinolytic throughout the case to reduce bleeding.

Since the patient agreed to the minor blood fractions, coagulation was optimized using cryoprecipitate and 4-factor prothrombin complex concentrate (PCC). To reduce bleeding, coagulation was monitored by thromboelastography (TEG) both during and after surgery. Postoperatively, the patient awoke without any neurologic deficits. He was discharged from  the ICU within 24 hours following surgery with a hemoglobin of 11.1 g/dL and a platelet count of 210K. Postoperative bleeding was minimal. The patient’s wife and family members were incredibly grateful for the care he received.

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The condition, lessons for the clinician, poster presentations:, section editor’s note, suggested readings, case 5: a 13-year-old boy with abdominal pain and diarrhea.

AUTHOR DISCLOSURE

Drs Sudhanthar, Okeafor, and Garg have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

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Anjali Garg , Sathyan Sudhanthar , Chioma Okeafor; Case 5: A 13-year-old Boy with Abdominal Pain and Diarrhea. Pediatr Rev December 2017; 38 (12): 572. https://doi.org/10.1542/pir.2016-0223

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A 13-year-old boy presents to his primary care provider with a 5-day history of abdominal pain and a 2-day history of diarrhea and vomiting. He describes the quality of the abdominal pain as sharp, originating in the epigastric region and radiating to his back, and exacerbated by movement. Additionally, he has had several episodes of nonbloody, nonbilious vomiting and watery diarrhea. His mother discloses that several family members at the time also have episodes of vomiting and diarrhea.

He admits to decreased oral intake throughout the duration of his symptoms. He denies any episodes of fever, weight loss, fatigue, night sweats, or chills. He also denies any hematochezia or hematemesis. His medical history is significant for a ventricular septal defect that was repaired at a young age, but otherwise no other remarkable history.

During the physical examination, the adolescent is afebrile and assessed to be well hydrated. Examination of the abdomen reveals tenderness in the epigastric region and the right lower quadrant on light to deep palpation, with radiation to his back on palpation. There are no visible marks or lesions on his abdomen. Physical examination is negative for rebound tenderness, rovsing sign, or psoas sign. The remainder of the examination findings are negative.

Complete blood cell count, liver enzyme levels, pancreatic enzyme levels, and urinalysis results are all within normal limits.

Our patient was asked to observe his hydration status and pain at home and to report any changes. However, he arrived at the emergency department the next day due to increased severity of abdominal pain. The pain had localized into the right lower quadrant. Further imaging revealed the diagnosis.

The differential diagnosis for an adolescent who presents with abdominal pain is broad, including gastrointestinal causes such as gastroenteritis, appendicitis, or constipation and renal causes such as nephrolithiasis or urinary tract infections. With our patient, the more plausible answers were ruled out through laboratory studies and physical examination, and he was assumed to have gastroenteritis based on the history of similar symptoms in his family members. However, with the worsening of his abdominal pain, further diagnostic study became imperative and a computed tomographic (CT) scan of the abdomen was obtained to assess for appendicitis or nephrolithiasis.

The CT scan showed a cecum located midline; the large intestine was on the left side of the abdomen, and the small intestine was on the right ( Figs 1 and 2 ). The appendix was buried deep in the right pelvis, and there was no indication of appendicitis. These findings were consistent with intestinal malrotation. Intestinal malrotation is rare beyond the first year of life. Maintaining a higher index of suspicion in any patient with an acute presentation of severe abdominal pain is imperative because of the severity of potential complications such as bowel obstruction, volvulus, and eventual necrosis. Our patient’s pain is assumed to have been due to compressive effects of the peritoneal bands (Ladd bands), which were irritated by an initial gastroenteritis. He did not have the signs or symptoms of a more severe complication, such as bowel obstruction or volvulus.

Computed tomographic scan of the abdomen showing intestinal malrotation, specifically of the subtype nonrotation. The small bowel is present in the right hemi-abdomen and the large bowel in the left hemi-abdomen. The cecum is midline in the pelvis. Haustra are still present, excluding any sign of obstruction.

Swirling appearance of the mesentery is known as the whirl sign, which is also indicative of malrotation. This computed tomographic scan shows the superior mesenteric vein wrapped around the superior mesenteric artery.

Owing to the severity of the pain, our patient was taken for surgery, specifically, a Ladd procedure and a prophylactic appendectomy. Ladd bands were seen to extend from the cecum to above the duodenum. During the procedure, these bands were lysed, then the mesentery was spread out, and the bowels were rearranged. He tolerated the surgery well and was discharged 3 days after the operation.

His abdominal pain improved after surgery, and he has been doing well at his postoperative checks.

Intestinal malrotation is when the intestines fail to rotate properly in utero. From the fifth to 10th weeks of embryologic development, the small intestine lies in the right aspect of the abdomen, with the ileocecal junction midline, and the large intestine in the left hemi-abdomen. The segments are then pushed out of the abdomen into the umbilical cord. Both segments grow in the first stage of rotation. During the second stage of rotation, the small intestine rotates counterclockwise 270 degrees around the superior mesenteric artery. The remaining intestine is pulled into the abdomen, and the mesentery is fixed to the retroperitoneal space. The large intestine comes in last, with the final segment of the cecum lying anterior to the small intestine in the right lower quadrant.

Nonrotation is the most frequent cause of intestinal malrotation. Nonrotation occurs when the 270-degree rotation does not occur and, thus, the mesentery is not fixed to the retroperitoneal space. Derangements of the second stage of rotation are defined as having the small intestine in the right hemi-abdomen, with the cecum midline in the pelvis, and the large intestine in the left hemi-abdomen.

One percent of the population has intestinal rotation disorders. The incidence decreases with age. Approximately 90% of patients are diagnosed within the first year of their life, with 80% among them within the first month after birth. Due to a delay in diagnosis, the 10% of patients who present beyond that first year after birth can have severe complications.

Symptoms of malrotation are different in infants compared with adolescents. Neonates typically will have bilious emesis. In contrast, children and adults commonly exhibit acute abdominal pain. Some older patients have had chronic abdominal pain that goes unnoticed; others may be asymptomatic before diagnosis. The co-occurrence of intestinal malrotation with congenital cardiac anomalies is a common finding. Twenty-seven percent of intestinal malrotation patients were found to have a concurrent cardiovascular defect such as ventricular septal defect or another minor/major abnormality.

The diagnostic modality of choice is an upper gastrointestinal tract contrast study. This study modality shows any obstruction and depicts the malrotation through contrast media. Sometimes a contrast medium is not needed for diagnosis, as in the case of our patient, where CT scanning was enough to diagnose the malrotation.

Asymptomatic neonates and all symptomatic individuals, regardless of age, go through the Ladd procedure to correct the abnormality. However, the guidelines are not as clear for treatment of children older than 1 year who are asymptomatic. Currently, there is some consensus for performance of the procedure regardless of symptom status because of the severity of the complications or mortality that can occur due to malrotation. The narrow pedicle of the mesentery that forms in malrotation is prone to volvulus and ischemia, leading to complications at any point in an individual’s life. A diagnostic laparoscopy should be performed at the very least and can be therapeutic as well. Removal of the appendix has been suggested to prevent any diagnostic complications on future presentation. Additionally, the Ladd procedure can lyse Ladd bands, which are abnormal fibrous adhesions from the cecum that also arch over the duodenum. Removal of these bands is imperative because they can cause intestinal obstruction and ischemia as well.

Diagnosis of intestinal malrotation should be considered in a patient presenting acutely with severe abdominal pain, especially in a patient with known cardiac anomalies.

Often the symptoms of intestinal malrotation can be vague, and a patient can be asymptomatic for years before presentation.

The diagnostic modality of choice is an upper gastrointestinal tract series, but other imaging, such as computed tomographic scan, can help diagnose the presence of malrotation in emergency situations.

A Ladd procedure should be conducted on a patient even if he/she does not have current symptoms of obstruction due to increased risk of obstruction or complications such as volvulus and gut necrosis with this disease.

This case is based on a presentation by Ms Anjali Garg and Drs Sathyan Sudhanthar and Chioma Okeafor at the 39th Annual Michigan Family Medicine Research Day Conference in Howell, MI, May 26, 2016.

Poster Session: Student and Resident Case Report Poster Presentation

Poster Number: 23

This case is based on a presentation by Ms Anjali Garg and Drs Sathyan Sudhanthar and Chioma Okeafor at the 2016 AAP National Conference and Exhibition in San Francisco, CA, October 22-25, 2016.

Poster Session: Section on Pediatric Trainees Clinical Case Competition

Abdominal Pain in Children: https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Abdominal-Pain-in-Children.aspx

Diarrhea: https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Diarrhea.aspx

For a comprehensive library of AAP parent handouts, please go to the Pediatric Patient Education site at http://patiented.aap.org .

This case was selected for publication from the finalists in the 2016 Clinical Case Presentation program for the Section on Pediatric Trainees of the American Academy of Pediatrics (AAP). Ms Anjali Garg, BS, was a medical student from Michigan State University College of Human Medicine, East Lansing, MI, when she wrote this case report, and she now is a medical resident at Rainbow Babies and Children's Hospital in Cleveland, OH. Choosing which case to publish involved consideration of not only the teaching value and excellence of writing but also the content needs of the journal. Other cases have been chosen from the finalists presented at the 2017 AAP National Conference and Exhibition and will be published in 2018.

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eTable 1. Search Strategy

eTable 2. Risk of Bias Assessment Using the Joanna Briggs Institute Critical Appraisal Checklist Tool

eTable 3. Time From Symptom Presentation to Diagnosis Measurement Across Studies

eFigure 1. Forest Plots of Proportions of Presenting Signs and Symptoms for EOCRC, by Sign or Symptom

eFigure 2. Pooled Proportions of Presenting Signs and Symptoms for EOCRC by Geography

eFigure 3. Pooled Proportions of Presenting Signs and Symptoms for EOCRC; Stratified Analysis by Age Group

eFigure 4. Pooled Proportions of Presenting Signs and Symptoms for EOCRC, Stratified Analysis by Risk of Bias

eFigure 5. Pooled Proportions of Presenting Signs and Symptoms for EOCRC, Stratified Analysis by Data Source

eFigure 6. Histograms of Mean and Median Diagnosis Stratified by Data Source

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Demb J , Kolb JM , Dounel J, et al. Red Flag Signs and Symptoms for Patients With Early-Onset Colorectal Cancer : A Systematic Review and Meta-Analysis . JAMA Netw Open. 2024;7(5):e2413157. doi:10.1001/jamanetworkopen.2024.13157

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Red Flag Signs and Symptoms for Patients With Early-Onset Colorectal Cancer : A Systematic Review and Meta-Analysis

• 1 Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla
• 2 Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, VA Greater Los Angeles Healthcare System, Los Angeles, California
• 3 Department of Medicine, University of California San Diego, La Jolla
• 4 Division of Gastroenterology, Washington University in St Louis, St Louis, Missouri
• 5 Department of Internal Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
• 6 Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
• 7 UC San Diego Library, University of California San Diego, La Jolla
• 8 University of Colorado Cancer Center, Colorado School of Public Health, Aurora
• 9 Molecular Medicine Unit, Department of Medicine, Biomedical Research Institute of Salamanca, University of Salamanca, Salamanca, Spain
• 10 Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, Tennessee
• 11 Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus, Aurora
• 12 Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla
• 13 Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
• 14 Jennifer Moreno Veteran Affairs San Diego Healthcare System, San Diego, California
• 15 Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
• 16 Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri
• 17 Surgery Department, Vithas Arturo Soria University Hospital, Madrid, Spain

Question   In patients with early-onset colorectal cancer (EOCRC), what are the most common presenting signs and symptoms, what is their association with EOCRC risk, and what is the time from presentation to diagnosis?

Findings   In this systematic review and meta-analysis including 81 studies and more than 24.9 million patients, nearly half of individuals with EOCRC presented with hematochezia and abdominal pain and one-quarter presented with altered bowel habits. Delays in diagnosis of 4 to 6 months from time of initial presentation were common.

Meaning   These findings underscore the need to identify signs and symptoms concerning for EOCRC and complete timely diagnostic workup for individuals without an alternative diagnosis or sign or symptom resolution.

Importance   Early-onset colorectal cancer (EOCRC), defined as a diagnosis at younger than age 50 years, is increasing, and so-called red flag signs and symptoms among these individuals are often missed, leading to diagnostic delays. Improved recognition of presenting signs and symptoms associated with EOCRC could facilitate more timely diagnosis and impact clinical outcomes.

Objective   To report the frequency of presenting red flag signs and symptoms among individuals with EOCRC, to examine their association with EOCRC risk, and to measure variation in time to diagnosis from sign or symptom presentation.

Data Sources   PubMed/MEDLINE, Embase, CINAHL, and Web of Science were searched from database inception through May 2023.

Study Selection   Studies that reported on sign and symptom presentation or time from sign and symptom presentation to diagnosis for patients younger than age 50 years diagnosed with nonhereditary CRC were included.

Data Extraction and Synthesis   Data extraction and quality assessment were performed independently in duplicate for all included studies using Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines. Joanna Briggs Institute Critical Appraisal tools were used to measure risk of bias. Data on frequency of signs and symptoms were pooled using a random-effects model.

Main Outcomes and Measures   Outcomes of interest were pooled proportions of signs and symptoms in patients with EOCRC, estimates for association of signs and symptoms with EOCRC risk, and time from sign or symptom presentation to EOCRC diagnosis.

Results   Of the 12 859 unique articles initially retrieved, 81 studies with 24 908 126 patients younger than 50 years were included. The most common presenting signs and symptoms, reported by 78 included studies, were hematochezia (pooled prevalence, 45% [95% CI, 40%-50%]), abdominal pain (pooled prevalence, 40% [95% CI, 35%-45%]), and altered bowel habits (pooled prevalence, 27% [95% CI, 22%-33%]). Hematochezia (estimate range, 5.2-54.0), abdominal pain (estimate range, 1.3-6.0), and anemia (estimate range, 2.1-10.8) were associated with higher EOCRC likelihood. Time from signs and symptoms presentation to EOCRC diagnosis was a mean (range) of 6.4 (1.8-13.7) months (23 studies) and a median (range) of 4 (2.0-8.7) months (16 studies).

Conclusions and Relevance   In this systematic review and meta-analysis of patients with EOCRC, nearly half of individuals presented with hematochezia and abdominal pain and one-quarter with altered bowel habits. Hematochezia was associated with at least 5-fold increased EOCRC risk. Delays in diagnosis of 4 to 6 months were common. These findings highlight the need to identify concerning EOCRC signs and symptoms and complete timely diagnostic workup, particularly for individuals without an alternative diagnosis or sign or symptom resolution.

The incidence of early-onset colorectal cancer (EOCRC), defined as a diagnosis at younger than age 50 years, has been increasing at an alarming rate, in contrast to the decreasing CRC rate among older individuals. 1 These trends have been observed globally, 2 - 9 and EOCRC rates in the US are projected to increase by at least 140% by 2030. 10 These worrisome epidemiologic findings prompted an update in US CRC screening guidelines to begin screening among individuals at average risk at age 45 years. 11

Outside of screening, early detection of symptomatic EOCRC remains a priority. Delayed diagnosis may be a result of late patient presentation and lack of clinician knowledge of common CRC symptoms, such as hematochezia or abdominal and pelvic pain, and signs, such as iron deficiency anemia. Patients and clinicians alike may downplay symptom severity and fail to recognize key red flags and clinical cues that should trigger suspicion of CRC. 12 - 15 Furthermore, diagnostic algorithms in adults younger than 50 years often favor a less invasive and more conservative watchful waiting strategy, which could result in missed opportunities for intervention. 16 Therefore, defining the prevalence of these common signs and symptoms and their associated EOCRC risk is a critical first step to inform care pathways.

Additionally, delays in diagnostic workup after sign or symptom presentation are up to 40% longer in younger compared with older individuals with CRC, which may contribute to greater proportion of late stage diagnosis (58%-89% vs 30%-63%) and increasing EOCRC mortality rates in the US (1.3% per year from 2008-2017). 17 - 20 Mitigation strategies to expedite timely diagnoses may help decrease EOCRC morbidity and mortality. To address these gaps and pressing clinical issues, we performed a systematic review and meta-analysis to quantify the prevalence of signs and symptoms at EOCRC presentation, their association with EOCRC risk, and time to diagnosis.

We conducted a systematic review and meta-analysis to answer 3 questions. First, which signs and symptoms are most commonly present in individuals diagnosed with EOCRC? Second, what is the association between EOCRC sign or symptom exposure and EOCRC risk? Third, what is the time from sign or symptom presentation to diagnosis of EOCRC? This study is registered on Prospero (identifier: CRD42020181296 ). We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses ( PRISMA ) reporting guideline.

A comprehensive literature search was performed in PubMed/MEDLINE, Embase, CINAHL, and Web of Science Core Collection from inception through May 2023 to identify candidate studies for inclusion (eTable 1 in Supplement 1 ). Results were exported and deduplicated in EndNote (Clarivate) using the Bramer method. 21

Study review and data extraction were performed in Covidence (Veritas Health Innovation). Two independent reviewers (among J. Demb, J.M.K, J. Dounel, C.D.L.F., S.M.A. and F.E.R.V.) screened titles and abstracts for eligibility and reviewed the full text of all designated articles, with a third reviewer (S.G.) providing consensus if needed. Studies that reported on sign or symptom presentation or time to diagnosis for patients younger than age 50 years diagnosed with nonhereditary CRC were included. Studies with fewer than 15 eligible patients, most patients younger than age 18 years, or published before 1996 or in which more than half of the study period occurred before 1996—the year when EOCRC incidence rates began increasing, notably among adults aged 40 to 49 years—were excluded. 22 Meeting abstracts, reviews, non-English articles, and nonoriginal research were excluded.

Two reviewers (J. Demb and J.M.K.) extracted relevant data from articles meeting inclusion criteria, including study characteristics (time period, design, country, and population composition), the proportion of patients with EOCRC presenting with each sign and symptom, relative estimates for association of signs and symptoms with EOCRC risk, and time from symptom presentation to diagnosis, as defined by either patient report of onset of symptoms or medical record capture of symptom presentation. Risk of bias assessment was performed using the Joanna Briggs Institute (JBI) Critical Appraisal tools for cohort studies, cross-sectional studies, and case-control studies. 23 These tools include questions characterizing a study’s sources of bias and internal validity, measurement of exposures, outcomes and follow-up, and potential risk of selection or information bias. Risk of bias was graded and separated into 3 categories: low risk, 75% to 100% of checklist items included; moderate risk, 50% to 75% of checklist items; and high risk, less than 50% of checklist items.

For the assessment of signs and symptoms among patients with EOCRC, sign and symptom proportions were pooled individually across studies and proportions were compared using forest plots. Pooled prevalence estimates were calculated via random-effects meta-analysis using the Hartung and Knapp method, which has been found to perform well when between-study heterogeneity is high and study sample sizes are similar. 24 , 25 Stratified analyses were performed to measure pooled estimates based on specific study characteristics to assess potential variations in estimates, including geographic study location (US vs non-US), study age groups (≤40 years and ≤50 years), risk of bias (low, moderate, high), and data source type (claims or medical record, patient-reported, not well defined). Meta-regression was also performed adjusting for percentage of male study participants and the year of study publication.

We assessed heterogeneity between study-specific estimates using the inconsistency index ( I 2 ), and used cutoffs of 0% to 30%, 30% to 60%, 60% to 90%, and 90% to 100% to suggest minimal, moderate, substantial, and considerable heterogeneity, respectively. Between-study sources of heterogeneity were investigated using subgroup analyses by stratifying original estimates according to study characteristics. In this analysis, P  < .10 differences between subgroups was considered statistically significant (ie, a value of P  < .10 suggests that stratifying based on that particular study characteristic partly explained the heterogeneity observed in the analysis).

Signs and symptoms with estimates of EOCRC risk across at least 3 studies were described using forest plots. Due to significant heterogeneity across studies, particularly the composition of the analytic samples, we were unable to conduct meta-analysis of signs and symptoms and their association with EOCRC risk. Time to diagnosis was defined as the date of sign or symptom presentation to the date of diagnosis and stratified according to the data source type, since this was measured differently across studies. These data were aggregated based on whether the estimate was a mean or median, and the distributions of mean and median times to diagnosis were evaluated.

P values were 2-sided, and statistical significance was set at P  < .10. All analyses were performed using R statistical software version 4.1.3 (R Project for Statistical Computing), with plots and statistical analyses calculated using the suite of functions and commands within the meta package and the ggplot2 package, with R code provided in the eMethods in Supplement 1 . 26 Data were analyzed from August 2022 and April 2024.

Of the 12 859 unique articles retrieved, 699 full texts were reviewed, and 81 studies 12 , 13 , 18 , 27 - 104 were included ( Figure 1 and Table ). There were 76 cross-sectional studies, 12 , 13 , 18 , 27 - 35 , 37 - 43 , 45 , 46 , 48 - 92 , 94 , 96 - 104 4 case-control studies, 44 , 47 , 93 , 95 and 1 cohort study. 36 Studies were performed in Africa (5 studies), 31 , 41 , 54 , 65 , 84 Asia or the Middle East (26 studies), 18 , 35 , 37 , 42 , 48 , 49 , 51 - 53 , 56 , 62 , 66 , 67 , 71 , 77 , 78 , 80 , 82 , 85 , 96 , 99 - 104 Europe (19 studies), 28 , 29 , 40 , 43 , 45 , 46 , 50 , 55 , 57 , 58 , 60 , 63 , 64 , 72 , 73 , 75 , 87 , 91 , 93 North America (23 studies), 12 , 27 , 32 - 34 , 36 , 39 , 44 , 47 , 59 , 61 , 68 - 70 , 74 , 81 , 86 , 88 , 92 , 94 , 95 , 97 , 98 South America (5 studies), 30 , 38 , 83 , 89 , 90 and Oceania (2 studies). 76 , 79 There were 67 studies 12 , 13 , 27 , 28 , 30 , 32 - 34 , 36 , 38 - 40 , 44 , 45 , 47 , 48 , 51 - 77 , 79 , 81 , 83 , 84 , 86 - 102 , 104 deemed to have low risk of bias, 10 studies 18 , 29 , 31 , 35 , 37 , 46 , 50 , 80 , 85 , 103 with moderate risk of bias, and 4 studies 41 , 49 , 78 , 82 with high risk of bias, based on JBI checklists. Notable sources of bias included using patient-reported or inadequately defined measures of signs or symptoms and time to diagnosis (eTable 2 in Supplement 1 ).

There were 78 studies 12 , 13 , 18 , 31 - 92 , 94 - 108 that reported on 17 signs and symptoms at presentation, based on claims or medical records (66 studies), 12 , 13 , 27 , 28 , 30 , 32 - 34 , 38 - 40 , 42 - 45 , 47 , 48 , 51 - 77 , 79 , 81 , 83 , 84 , 86 - 92 , 94 - 104 patient report (6 studies), 18 , 29 , 37 , 46 , 80 , 82 or other (7 studies). 31 , 35 , 41 , 49 , 50 , 78 , 85 ( Figure 2 ; eFigure 1 in Supplement 1 ). In adults with EOCRC, the 3 most common presenting signs and symptoms were hematochezia (pooled prevalence, 45% [95% CI, 40%-50%]; 76 studies), 12 , 13 , 18 , 27 - 31 , 33 - 35 , 37 - 63 , 65 - 92 , 94 - 102 , 104 abdominal pain (pooled prevalence, 40% [95% CI, 35%-45%]; 73 studies), 12 , 13 , 18 , 27 - 31 , 33 - 35 , 37 - 40 , 42 - 67 , 70 - 85 , 87 - 92 , 94 - 102 , 104 and altered bowel habits, which included constipation, diarrhea, alternating bowel habits, or alternating diarrhea or constipation (pooled prevalence, 27% [95% CI, 22%-33%]; 63 studies). 12 , 18 , 28 - 31 , 33 - 35 , 37 - 39 , 43 - 68 , 70 - 72 , 74 - 80 , 83 - 85 , 87 , 88 , 90 , 92 , 94 - 96 , 98 - 100 , 102 , 104

When evaluating patterns by geography, the 3 most common presenting signs and symptoms were the same in both the US (20 studies) 12 , 33 , 34 , 39 , 44 , 47 , 59 , 61 , 68 - 70 , 74 , 81 , 86 , 88 , 92 , 94 , 95 , 97 , 98 and non-US (58 studies) 13 , 27 - 29 , 35 , 37 , 38 , 40 - 43 , 45 , 46 , 48 - 58 , 60 , 62 - 67 , 71 - 73 , 75 - 80 , 82 - 85 , 87 , 89 - 91 , 96 , 99 - 102 , 104 studies (eFigure 2 in Supplement 1 ). When stratifying by age of study population, there were 42 studies 12 , 18 , 28 - 30 , 32 - 34 , 38 - 40 , 42 , 44 , 45 , 48 , 50 , 54 , 61 , 62 , 67 , 69 - 71 , 74 , 75 , 78 , 80 , 82 , 86 - 92 , 94 - 100 including adults aged 50 years or younger and 25 studies 31 , 35 , 37 , 41 , 43 , 46 , 47 , 49 , 51 , 53 , 55 , 56 , 59 , 60 , 63 - 66 , 68 , 72 , 77 , 81 , 83 - 85 including adults aged 40 years and younger. In both groups, the top 3 presenting signs and symptoms were consistent with the primary results (eFigure 3 in Supplement 1 ). Primary results were unchanged in studies with low risk of bias; although in studies with moderate risk of bias, the 3 most common presenting signs and symptoms varied: hematochezia (pooled prevalence, 43% [95% CI, 34%-53%]; 9 studies), abdominal pain (pooled prevalence, 36% [95% CI, 26%-48%]; 9 studies) and obstruction (pooled prevalence, 24% [95% CI. 16%-33%]; 2 studies) (eFigure 4 in Supplement 1 ). When examining data source used to ascertain presenting sign or symptom, only studies with a poorly defined data source showed alternative most common presenting symptoms: loss of appetite (pooled prevalence, 58% [95% CI, 40%-74%]; 2 studies), hematochezia (pooled prevalence, 57% [95% CI, 37%-75%]; 7 studies), and abdominal pain (pooled prevalence, 54% [95% CI, 36%-71%]; 6 studies) (eFigure 5 in Supplement 1 ). Meta-regression analyses by percentage of male study participants or year of study publication across the 17 signs and symptoms for CRC were not found to account for a significant amount of between-study heterogeneity.

There were 5 studies 36 , 44 , 47 , 93 , 95 examining the association of EOCRC risk with abdominal pain, anemia, constipation, diarrhea, hematochezia, and nausea or vomiting ( Figure 3 ). Hematochezia (relative estimate range, 5.2-54.0; 5 studies), 36 , 44 , 47 , 93 , 95 abdominal pain (relative estimate range, 1.3-6.0; 4 studies), 44 , 47 , 93 , 95 and anemia (relative estimate range, 2.1-10.8; 3 studies) 36 , 44 , 47 were associated with higher likelihood of CRC compared with no CRC.

There were 34 studies 18 , 28 , 29 , 31 - 34 , 37 , 38 , 41 , 43 , 44 , 50 , 52 - 54 , 56 - 58 , 61 , 62 , 71 , 75 , 80 , 81 , 83 - 86 , 88 , 90 , 94 , 96 , 104 that reported a continuous measure of time from sign or symptom presentation to diagnosis, with 23 studies providing a mean result and 16 studies providing a median result (eTable 3 in Supplement 1 ). The time from symptom onset to EOCRC diagnosis was reported as a mean (range) of 6.4 (1.8-13.7) months and a median (range) of 4.1 (2.0-8.7) months ( Figure 4 ). When classifying time from sign or symptom onset to diagnosis by measurement type (medical record, patient reported, not well defined), there was considerable heterogeneity. When excluding studies with inadequately defined data sources, the time from symptom onset to EOCRC diagnosis was a mean (range) of 6.6 (3.0-13.7) months and median (range) of 3.8 (2.0-8.7) months (eFigure 6 in Supplement 1 ).

In this systematic review and meta-analysis, nearly half of individuals diagnosed with EOCRC presented with hematochezia and abdominal pain, which were associated with 5- to 54-fold and 1.3- to 6-fold increased likelihood of CRC, respectively. An interval of 4 to 6 months from symptom onset to EOCRC diagnosis was common. These findings underscore the need for clinicians to consider EOCRC as part of the differential diagnosis for patients presenting with potential red flag signs and symptoms, and to follow up through either confirmation of diagnosis and sign or symptom resolution when a benign cause is suspected, or colonoscopy referral to rule out CRC based on sign or symptom severity or absence of diagnosis or sign or symptom resolution after initial workup and management for a suspected benign cause.

Our finding that 45% of individuals with EOCRC presented with hematochezia aligns with current clinical paradigms—hematochezia (or rectal bleeding) is often cited as a common presenting symptom among patients with CRC. 105 In addition, the 5 studies 36 , 44 , 47 , 93 , 95 that measured the association between hematochezia and EOCRC risk found estimates between 5.1 and 54.0, underscoring the urgent need for these patients to undergo comprehensive diagnostic evaluation. A full colonoscopy should be pursued when individuals younger than 50 years present with hematochezia, according to guidelines from the American Society for Gastrointestinal Endoscopy and European Panel on the Appropriateness of Gastrointestinal Endoscopy. 106 , 107 A high index of suspicion for CRC in younger patients with hematochezia may be particularly useful to identify patients with high risk, given the high frequency and association with CRC.

Our review also found that nearly half of individuals with EOCRC reported abdominal pain, based on evidence from 73 studies 12 , 13 , 18 , 27 - 31 , 33 - 35 , 37 - 40 , 42 - 67 , 70 - 85 , 87 - 92 , 94 - 102 , 104 and a 1.3- to 6-fold positive association with EOCRC risk across 4 studies. 44 , 47 , 93 , 95 Given its association with a myriad of gastrointestinal conditions, the American Academy of Family Physicians recommends computed tomography for evaluating patients with acute right or left lower quadrant abdominal pain and ultrasonography for right upper quadrant pain, though the guidelines also recommend identifying associated symptoms to better focus a differential diagnosis. 108 It may be inefficient and unrealistic to perform colonoscopy for all adults younger than 45 years with isolated abdominal pain, given the low diagnostic yield 109 and insufficient capacity across the US to accommodate this group. Nevertheless, the fact that 40% of patients with EOCRC presented with abdominal pain and 27% presented with altered bowel habits reinforces that any new symptom should be comprehensively evaluated by a clinician. Our findings suggest that EOCRC should be part of the initial differential diagnosis, and that a plan for follow-up should be in place, such as a 30- to 60-day follow-up visit to confirm whether the original working diagnosis was correct, the red flag sign or symptom has resolved, or to refer for colonoscopy to exclude EOCRC if these criteria are not met. 110 We postulate that all benign causes of red flag signs or symptoms either can be diagnostically confirmed or should resolve with initial treatment. When an alternative diagnosis is not confirmed or signs or symptoms fail to resolve, a colonoscopy to rule out EOCRC should be pursued. Abdominal pain could serve as a marker to prompt further patient-clinician discussion about additional medical history, which could help determine whether further diagnostic work-up is warranted.

Globally and in the US, hematochezia, abdominal pain, and altered bowel habits were the 3 most common signs and symptoms. The fourth most common symptom differed based on geographic location—diarrhea among US studies and loss of appetite in non-US studies. The findings highlight how nonspecific symptoms are frequently present at EOCRC diagnosis and emphasize the need for medical professionals to be aware of the symptoms most associated with EOCRC, to refine clinical practice pathways and minimize late EOCRC detection.

The mean time from sign or symptom onset to EOCRC diagnosis was found to be 6.4 months (median, 4 months). A recent study using administrative claims data in Canada from 2003 to 2018 reported the greatest delay occurring between the first investigation and diagnosis (78 days) with short turnaround times between presentation and first investigation (5 days) or diagnosis and treatment start (23 days). Date of first presentation was defined by the physician visit related to the diagnostic examination (endoscopy, surgery, or imaging). 111 The data are mixed on whether decreasing time to diagnosis would improve outcomes, but it is well established that risk for progression to more advanced-stage disease increases over time. Another claims-based study from Canada found that young individuals with CRC had longer diagnostic intervals compared with middle-aged patients, although young patients with metastatic EOCRC had a short diagnostic interval, likely due to more noticeable or concerning symptoms. 32 Other studies found that differences between older and younger patients with CRC in stage at presentation were not just associated with delayed diagnosis, but could be associated with additional biological and genetic factors. 33

Nevertheless, it is prudent to address potential physician and patient barriers to timely workup. Younger patients may experience ongoing signs and symptoms and delay seeking medical attention. 88 Potential reasons for these delays include a patient believing they are too young to worry about cancer or a lack of access to primary care or health insurance. 88 , 110 Clarifying how these signs and symptoms are associated with EOCRC could give patients greater urgency to report these symptoms sooner, leading to quicker diagnostic workup and resolution. For clinicians, particularly those in primary care, recognition of clues and appropriate diagnostic workup for concerning signs and symptoms is paramount to early EOCRC detection. However, prior studies found that clinicians often dismiss these signs and symptoms or misattribute them to more benign conditions, such as attributing rectal bleeding to hemorrhoids, without conducting further diagnostic evaluation. 15 , 112 This can leave a potentially concerning sign or symptom unresolved for an extended period of time, and for some patients, delay EOCRC diagnosis. To avoid missing an EOCRC diagnosis, clinicians should work with patients to ensure concerning signs and symptoms undergo diagnostic evaluation to identify and resolve the underlying cause.

Our study has several strengths. Our approach distilled a tremendous amount of global data over several decades into clear and practical information that is immediately useful to clinicians. We applied strict study selection criteria to capture only individuals younger than 50 years with nonhereditary CRC to represent an individual with average risk diagnosed with EOCRC beginning in 1996, when EOCRC rates started to increase. The meta-analysis adjusted for or stratified by potential contributors to study heterogeneity, including study quality, age of study population, country of study origin, percentage of male study participants, and year of publication.

Our study has some limitations. There was significant heterogeneity across studies, which impacted our ability to meta-analyze some of our results. This was most significant in assessment of the associations of signs and symptoms with EOCRC, where a lack of a consistent comparator group hindered our ability to pool estimates for the associations. Additionally, we were unable to compare EOCRC risk against other potential outcomes, which might have better contextualized the relative risk. In our measurement of association of signs and symptoms with EOCRC, studies did not measure the potential likelihood of reverse causation—whether EOCRC was associated with sign or symptom presentation. We were unable to evaluate the impact of time to diagnosis on CRC outcomes due to a limited number of studies answering this question. In addition, sign- and symptom-based data extracted from studies used in this review were often extracted cross-sectionally to characterize patients with EOCRC at study baseline, limiting our access to stratified or more granular results by age, sex, race and ethnicity, or genetic ancestry, which could have better contextualized the burden of signs and symptoms and relevant EOCRC risk. We were unable to examine the constellation of signs and symptoms since we lacked individual-level data from each study and could not provide a positive predictive value for symptoms. However, we anticipate patients may have presented with multiple signs and symptoms and encourage clinicians to consider the full list of common presenting signs and symptoms and their prevalence to aid in EOCRC risk assessment.

This systematic review and meta-analysis of studies examining sign and symptom presentation of EOCRC found that hematochezia, abdominal pain, altered bowel habits, and unexplained weight loss were the most common presenting signs and symptoms in patients diagnosed with EOCRC. Markedly increased EOCRC risk was seen in adults with hematochezia and abdominal pain. Furthermore, time from sign or symptom presentation to EOCRC diagnosis was often between 4 and 6 months. These findings and the increasing risk of CRC in individuals younger than 50 years highlight the urgent need to educate clinicians and patients about these signs and symptoms to ensure that diagnostic workup and resolution are not delayed. Adapting current clinical practice to identify and address these signs and symptoms through careful clinical triage and follow-up could help limit morbidity and mortality associated with EOCRC.

Accepted for Publication: March 19, 2024.

Published: May 24, 2024. doi:10.1001/jamanetworkopen.2024.13157

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Demb J et al. JAMA Network Open .

Corresponding Author: Joshua Demb, PhD, MPH, Division of Gastroenterology, Department of Medicine, University of California, San Diego, 3350 La Jolla Village Dr, Bldg 13, San Diego, CA 92126 ( [email protected] ).

Author Contributions: Drs Demb and Kolb had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Demb and Kolb are co–first authors.

Concept and design: Demb, Kolb, Fritz, Advani, Cao, Dwyer, Heskett, Lieu, Singh, Vuik, Gupta.

Acquisition, analysis, or interpretation of data: Demb, Kolb, Dounel, Fritz, Cao, Coppernoll-Blach, Perea, Heskett, Holowatyj, Lieu, Singh, Spaander, Gupta.

Drafting of the manuscript: Demb, Kolb, Dounel, Fritz, Advani, Dwyer, Heskett, Lieu.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Demb, Singh.

Administrative, technical, or material support: Dwyer, Heskett, Gupta.

Supervision: Demb, Kolb, Advani, Perea, Spaander, Gupta.

Conflict of Interest Disclosures: Dr Holowatyj reported receiving grants from National Institutes of Health, American Cancer Society, Pfizer, Dalton Family Foundation, and ACPMP Research Foundation and personal fees from MJH Life Sciences outside the submitted work. Dr Gupta reported receiving personal fees from Guardant Health, Universal Diagnostics, Geneoscopy, and InterVenn Biosciences and owning stock in CellMax Life outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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• Takashi Shigeno 1 , 2 ,
• Daisuke Kajiyama 1 ,
• Kazuma Sato 1 ,
• Naoto Fujiwara 1 ,
• Yusuke Kinugasa 2 ,
• Hiroyuki Daiko 3 &
• Takeo Fujita 1  

Abdominal para-aortic lymph nodes (PANs) are sites of distant metastasis in esophageal squamous cell cancer (ESCC). The prognosis of patients with Stage IVB ESCC and abdominal PAN metastasis is extremely poor. However, chemotherapy for ESCC has recently been developed, and the effectiveness of combined induction therapy and conversion surgery remains unclear. The primary objective of this study was to evaluate the short- and long-term outcomes of conversion surgery for ESCC and solitary abdominal PAN metastases after induction therapy.

Thirteen patients who underwent conversion esophagectomy for cStage IVB ESCC with solitary abdominal PAN metastasis after induction therapy between January 2017 and October 2022 at our institution were enrolled. The short- and long-term outcomes of conversion surgery were retrospectively evaluated.

Three patients (23.1%) had pathological abdominal PAN metastasis, and six patients (46.2%) without pathological abdominal PAN metastasis showed that chemotherapy eliminated the tumors in the abdominal PAN. Three patients (23.1%) had postoperative complications of Clavien–Dindo grade II or higher. The 3-year overall and recurrence-free survival rates were 83.1% and 51.3%, respectively.

Conclusions

Our findings showed that conversion surgery for ESCC and solitary abdominal PAN metastasis led to a good prognosis when induction therapy was successful.

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Abbreviations

5-Fluorouraci

Adjuvant chemotherapy

Body mass index

Clavien–Dindo classification

Confidential interval

Computed tomography

Esophageal squamous cell carcinoma

Folinic acid, fluorouracil, and oxaliplatin

5-Fluorouracil and cisplatin

Japan Clinical Oncology Group

Lower thoracic esophagus

Neo-adjuvant chemotherapy

Not applicable

Middle thoracic esophagus

Overall survival

Para-aortic lymph node

Positron emission tomography–computed tomography

Partial response

Pathological residual tumor

Response Evaluation Criteria in Solid Tumors

Relapse-free survival

Radiation therapy

Stable disease

Union of international Cancer Control

Upper thoracic esophagus

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Acknowledgements

We wish to thank all patients and hospital staff who were involved in this study. We also thank Cathel Kerr, BSc, PhD and H. Nikki March, PhD, from Edanz ( https://jp.edanz.com/ac ) for editing a draft of this manuscript.

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Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan

Takashi Shigeno, Daisuke Kajiyama, Kazuma Sato, Naoto Fujiwara & Takeo Fujita

Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan

Takashi Shigeno & Yusuke Kinugasa

Esophageal Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan

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Contributions

Study design: TS and TF. Data collection: TS, DK, KS, NF, and TF. Statistical analysis.

Interpretation of results: TS and TF. Drafting of the manuscript: TS. Critical revision of the manuscript for important intellectual content: YK, HD, and TF. Final approval of the manuscript: All authors. Accountability for all aspects of the work: All authors.

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Correspondence to Takeo Fujita .

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All procedures were conducted in accordance with the ethical standards of the respective committees on human experimentation (institutional and national) and the Declaration of Helsinki. This study was approved by the National Cancer Center Research Ethics Review Committee (Research Project Number: 2018–322).

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595_2024_2872_MOESM1_ESM.pptx

Supplementary file1 Supplemental Figure 1. Abdominal PAN images of all 13 patients using contrast-enhanced computed tomography and positron emission tomography-computed tomography (PPTX 14192 KB)

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Shigeno, T., Kajiyama, D., Sato, K. et al. Efficiency of conversion surgery for esophageal squamous cell carcinoma with solitary abdominal para-aortic lymph node metastasis. Surg Today (2024). https://doi.org/10.1007/s00595-024-02872-4

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The dilemma of incidental findings in abdominal surgery: A cross-sectional study

Baraa shebli.

a Department of Cardiology, Aleppo University Hospital, Aleppo, Syria

Ahmad Rami Rahmeh

b Department of Ophthalmology, Aleppo University Hospital, Aleppo, Syria

Joud Khalili

c University of Aleppo, Aleppo, Syria

Joudi Sawas

d Department of Pediatrics, Aleppo University Hospital, Aleppo, Syria

Hala Mohamed Fares

e Department of General Surgery, Aleppo University Hospital, Aleppo, Syria

Kusay Ayoub

f Instructor General Surgery, Department of General Surgery, Aleppo University Hospital, Aleppo, Syria

Associated Data

Introduction.

Despite the recent development in diagnostic techniques, many surgeons experience unexpected findings during the course of surgery. We aim to examine the incidence of all IFs in abdominal surgery -laparoscopy or laparotomy- and identify possible associations.

This study is a cross-sectional study conducted in Aleppo University Hospital - Department of Surgery. We collected patients' data who underwent abdominal surgery during the period of the two-consecutive years 2018–2019.

The data revealed detection of incidental findings during abdominal surgery -which included proper inspection of peritoneal cavity-in 6 out 543 cases (1.1%), whereas only one case included a misdiagnosis event (0.2%).

Epidemiological information about IFs in abdominal surgery can be extremely useful for the surgeons on various aspects, and can assist them with being more prepared for the surgery and the possible unexpected lesions that might be encountered. We strongly recommend that further studies with larger numbers of participants are conducted as they can provide more generalizable data.

• • There is a lack in epidemiologic data regarding incidental findings in abdominal surgery.
• • Epidemiological data might be of great benefit for the surgeons when obtained prior to surgery.
• • The incidence of incidental findings in abdominal surgery is estimated to be 1.1%.

Abbreviations

1. introduction.

Despite the recent advancement in imaging techniques, many surgeons encounter till this day unexpected findings during the course of surgery [ 1 , 2 ]. Many authors defined an Incidental Finding (IF) as an unexpected lesion or condition found in an operation that is unrelated to the original condition that the patient had consented to.

IF may pose a hard challenge on the surgeon on several aspects. Firstly, the operating technique and instruments might differ according to the emerging IF; secondly, the patient did not consent to the new procedure for the IF, so this may render the surgeon hesitant whether to proceed or not.

Many studies reported the incidence of specific incidental findings in specific procedures; for example, Viscido et al. reported the incidence of Gastrointestinal Stromal Tumors (GISTs) in sleeve gastrectomy patients [ 3 ]; however, to our knowledge, there is no study that reports the incidence of total IFs in all abdominal surgeries and the possible associations with specific patient characteristics or specific surgical indications.

We aim to investigate the incidence of all IFs in abdominal surgery (whether laparoscopy or laparotomy) and identify possible associations.

This is a cross-sectional study conducted in Aleppo University Hospital - Department of Surgery. We collected patients' data; who underwent abdominal surgery during the period of the two consecutive years 2018–2019, in a retrospective manner. Written informed consent was obtained from the patient for the purpose of publication of this cross-sectional study. All study has been conducted in compliance with STROCSS criteria [ 4 ]. This study has been registered in ClinicalTrials.gov public registry with the unique identifying number of “ {"type":"clinical-trial","attrs":{"text":"NCT 05227911","term_id":"NCT05227911"}} NCT 05227911 ” https://www.clinicaltrials.gov/ct2/show/ {"type":"clinical-trial","attrs":{"text":"NCT05227911","term_id":"NCT05227911"}} NCT05227911 ?term=NCT+05227911&draw=2&rank=1 [ 5 ].

We collected data about patients' characteristics such as gender and age and specific information was collected regarding the abdominal surgery performed. For each operation, we collected data about the presence of IFs, and if present, how the surgeon dealt with it. We also collected data regarding any misdiagnosis event and how the surgeon approached the new condition. The data were assembled in an Excel sheet and then reviewed multiple times to check for integrity and flaws.

Inclusion criteria were: 1) patients older than 13 y/o 2) patients undergoing laparoscopy or laparotomy that must include a proper inspection of the abdominal cavity. Exclusion criteria: 1) patients aged 13 y/o or less 2) patients with incomplete data 3) gynecological procedures even if it involves laparotomy or laparoscopy.

We conducted Shapiro-Wilk Test of normality when required, and Fisher's exact test to study the possible associations in categorical data. Statistical significance level of 5% (p-value 0.05) was adopted. All statistical and analytical processes were done using MS Excel 2016 and SPSS version 26. The study was approved by the Ethical Committee in Aleppo University Hospital.

After the application of eligibility criteria, a total of 534 patients were enrolled in the study during the period of two consecutive years (2018–2019). The data showed an incidence of incidental findings detection during abdominal surgery -which included proper inspection of the peritoneal cavity-of 6 in 543 cases (1.1%), whereas only one case included a misdiagnosis event (0.2%). The median age of the participants was 42 with a range of 72 (13–85) years. The study enrolled 383 females (71.7%) and 151 males (28.3%). Most of the operations were laparoscopic (68.9%), while only 166 operations (31.1%) were laparotomy.

The most common indication for abdominal surgery in the study was Cholecystitis with 356 cases (66.7%) followed by Appendicitis with 53 cases (9.9%). The majority of cholecystectomy patients were females 81.2%. Further information about the most common indications is illustrated in Table 1 , and Table 2 .

Showing the distribution of gender in cholecystectomy patients.

This table shows the most common indications of abdominal surgery.

In order to investigate the association between the type of the procedure and the detection of incidental findings, we applied Fisher's exact test. A statistically significant association was not found (p-value = 0.381) between the type of the procedure -whether performed by laparoscopy or by laparotomy- and the detection of an IF, probably due to the limited number of patients. We studied also the association between the gender of the patient and the probability of detecting IFs using the same test, which also showed no statistically significant association between them. (p-value: 0.678)

Two out of six IFs were Polycystic Ovary Syndrome (PCO) and were managed with Ovarian drilling. Two out of six IFs were Appendicitis detected during bowel perforation procedures (one in the sigmoid and the other in the pylorus) and were resected. An ileocecal tumor was found during a cholecystitis procedure and the mass was resected; and at last, nodular lesions on the liver were found during a cholecystectomy procedure indicated for a gall bladder polyp and a biopsy of the nodules was obtained. Regarding the misdiagnosis event, the indication of the procedure was appendicitis but upon laparotomy, an ectopic pregnancy was diagnosed and managed accordingly. Table 3 .

This table shows the characteristics of cases with incidental finding or misdiagnosis.

AbbreviationsPCO: Polycystic Ovary.

Noteworthy, although we did not consider a finding that is an extension of the same lesion as an IF, we will only report those cases in tumors. six cases (1.1%) with suspected or confirmed tumor indication were found to be much more extensive than suggested by preoperative imaging modalities.

4. Discussion

Abdominal surgery involving the abdominal cavity is one of the most common types of surgeries worldwide. An Incidental Findings (IF) in surgery is defined as an unexpected lesion that is found during the course of a surgical procedure and is not related or considered an extension of the original lesion. If the finding can be suspected by a competent surgeon (e.g., a more extensive lesion or a possible differential diagnosis) then it will not be considered as an IF [ 1 , 2 ].

IF may render the surgeon in a rather difficult challenge. First of all, the patient did not give the surgeon consent to deal with the recently identified lesion. Second of all, the surgeon might not be fully prepared to deal with the new lesions; whether prepared with the surgical equipment required for the procedure or with specific technical information regarding the surgical technique.

Few papers have reviewed the topic of IFs; however, they dealt mostly with specific types of surgeries and specific types of IFs related to them, for example, Cazzo et al. reported a 1.1% incidence of mesenchymal tumors discovered as an incidental finding during gastric Roux-en-Y gastric bypass surgery [ 6 ]. Others, such as Hall et al., provided several possibilities of IFs and recommendations on how to deal with them [ 7 ].

To our knowledge, there is no study to date that provides epidemiological data about IF for the surgeon in abdominal surgery, helps with the anticipation of what type of IF could be encountered, and what risk factors are associated with increased incidence of IFs. Such studies might be very helpful for the surgical team as they can be more prepared for the most probable IF according to the type of surgery and other various patients' related characteristics.

Our study reports a 1.1% incidence (6 out 534) of IFs in all indicated abdominal surgeries in our institution, and a 0.2% incidence (1 out of 534) of misdiagnosis. The most common indication for surgery was cholecystectomy accounting for 66.7% of all cases and followed by appendicitis (9.9%). No statistically significant association was found between the detection of IF and the gender or the type of surgery (laparoscopy or laparotomy). In 1.1% (6 out of 543) of the cases involved a tumor that was found more extensive than suggested by preoperative imaging. This is important as this might change the management plan of the patient; e.g., a 64-year-old female underwent a Magnetic resonance Cholangiopancreatography (MRCP) and Computed Tomography (CT) that showed a respectable pancreatic head tumor. Upon laparotomy, the mass was found to be more infiltrated than shown by imaging modalities and complete resection was impossible.

Reviewing the medical literature, we found multiple possibilities when facing an incidental finding (IF):

• 1. The surgeon might face an unexpected finding, however, the surgeon knows that there is nothing that needs to be done in this regard, for example, Eze et al. reported the presence of pancake kidney in an abdominal aortic aneurysm operation’; however, they did not make any intervention regarding this kidney [ 8 ].
• 2. The surgeon might confront an IF and know immediately that there is definitely something need to be done regarding this IF, for example, Khurana et al. found a small nodule of renal cell carcinoma in the kidney of the donor during kidney transplant operation, so they resected the small nodule immediately [ 9 ]. Another example reported by Wilson et al. in an inguinal hernia operation, where they found a ruptured abdominal aortic aneurysm and they managed the condition immediately [ 10 ].
• 3. However, most times, it is not as obvious as mentioned above, and the surgeon does not know immediately which decision falls better in the patient's best interest. Frequently, long discussions might be needed in the operation room among surgeons, followed by a prolonged explanation to the patient's legal presentative to obtain consent to operate the new emerging condition; such situations can be very stressful for the patient's presentative and mainly for the surgeon in the operation room. In this specific case, studies similar to this one can be very helpful to reduce such situations and help the surgeon be more prepared regarding the best practice on how to deal with most common encountered IFs; and even may prepare the patient previously by obtaining a clause in the consent regarding the management of IFs; this approach was strongly supported in the cross-sectional study conducted by McKenzie et al. [ 11 ].

Epidemiological information regarding IFs similar to the provided by this manuscript might be of great benefit for surgeons prior to surgery [ 6 , 7 ]. For example, several studies reported the incidence of mesenchymal tumors during bariatric surgeries, so when the surgeon has such knowledge in advance, this can facilitate the process of decision-making in surgery. The surgeon can obtain consent to proceed in operating the possible IF (in this example a mesenchymal tumor) from the patient prior to surgery, and can be better prepared to deal with this tumor scientifically and technically.

Regarding the patient's consent, this topic has been a long-standing debatable topic in the medical literature with no definite guideline. Many recommendations or instructions vary according to the laws of the country, the surgeon who is operating, the patient's perspectives, and the incidental condition itself. Although it is controversial in many cases to proceed to operate the IF without the consent of the patient, it is widely accepted by most of the authors and systems that the surgeon can always proceed to operate any IF that may threaten the life of the patient if not treated immediately. Many authors such as Anderson et al., and Sarkar et al., proposed a traffic light tool to help the surgeons in the process of decision making in such situations [ 1 , 12 ]; however, these tools have not been yet tested in real practice.

The data in Table 3 show the types of IFs detected in our study. We encourage each surgeon to be prepared technically to deal with PCO if the operation is on a young female patient. The surgeon should always inspect the right iliac fossa properly to look for signs of an inflamed appendix. Good inspection of all cavities and mainly the areas of common tumors is mandatory; as a tumor, which has been overlooked by preoperational diagnostic modalities, might be detected. We also believe it is important to think beyond the findings of imaging modalities, as they can sometimes be insufficient or misleading especially in tumor staging. Finally, we recommend obtaining informed consent for these probable findings preoperatively, if a proper explanation for the patient can be delivered.

One limitation of the study was the relatively small number of participants which did not permit a proper identification of possible associations between IFs and specific patients' characteristics or specific surgical variables. Another limitation is the incomplete data for some patients, e.g., sometimes when multiple war-related injuries that overcome the capacity of the hospital were admitted, some patients’ data were incomplete so we excluded these cases.

In conclusion, epidemiological information about IFs in abdominal surgery might be very helpful for the surgeon on various aspects and can help to be much more prepared for the surgery and the possible unexpected lesions that might appear. We strongly recommend that further studies with larger numbers of participants are conducted as they can provide more generalizable data and identify other possible associations or risk factors for IFs.

Ethical approval

Written informed consent was obtained from the patient for publication of this cross-sectional study and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

The research did not receive any funding of any kind.

Author contribution

Conception or design of the work: BS, ARR, KA.

Data collection: BS, ARR, JS, JK.

Performed the analysis: ARR, BS.

Drafting the article: JK, BS, JS, ARR.

Critical revision of the article: BS, KA.

Final approval of the version to be published: BS, JS, ARR, JK, KA.

Trail Register.Number

• 1. Name of the registry: Incidental Findings in Abdominal Surgery.
• 2. Unique Identifying number or registration ID: {"type":"clinical-trial","attrs":{"text":"NCT 05227911","term_id":"NCT05227911"}} NCT 05227911 .
• 3 Hyperlink to your specific registration (must be publicly accessible and will be checked): https://clinicaltrials.gov/ct2/show/ {"type":"clinical-trial","attrs":{"text":"NCT05227911","term_id":"NCT05227911"}} NCT05227911

The Guarantor is: Baraa Shebli.

SA fully informed written and signed consent was obtained and documented in paper.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest

There is not any kind of conflict of interest to disclose.

Acknowledgments

We would like to thank Ayham Alzahran (Internal Medicine resident, department of Internal Medicine, Aleppo university hospital, Aleppo, Syria) and Ali Mansour (orthopedic resident, department of orthopedic, Aleppo university hospital, Aleppo, Syria) for their support during this work.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.amsu.2022.104470 .

Appendix A. Supplementary data

The following is the Supplementary data to this article:

Blood in Stool, Abdominal Pain Top Red Flags for Early-Onset Colorectal Cancer

— these symptoms are "frequently ignored by providers as trivial," according to one expert.

by Tara Haelle , Contributing Writer, MedPage Today May 24, 2024

The most common red flag signs and symptoms of early-onset colorectal cancer (CRC) included hematochezia, abdominal pain, and altered bowel habits, according to a systematic review and meta-analysis.

Of nearly 25 million patients younger than 50 in 81 studies, the most common presenting signs and symptoms of early-onset CRC were hematochezia (pooled prevalence 45%, 95% CI 40-50), abdominal pain (pooled prevalence 40%, 95% CI 35-45), and altered bowel habits (pooled prevalence 27%, 95% CI 22-33), reported Joshua Demb, PhD, MPH, of the University of California San Diego, and colleagues.

In addition, hematochezia (relative estimate range 5.2-54.0), abdominal pain (relative estimate range 1.3-6.0), and anemia (relative estimate range 2.1-10.8) were associated with higher likelihood of early-onset CRC compared with no CRC, they noted in JAMA Network Open .

"These findings underscore the need for clinicians to consider early-onset CRC as part of the differential diagnosis for patients presenting with potential red flag signs and symptoms, and to follow up through either confirmation of diagnosis and sign or symptom resolution when a benign cause is suspected, or colonoscopy referral to rule out CRC based on sign or symptom severity or absence of diagnosis or sign or symptom resolution after initial workup and management for a suspected benign cause," Demb and team wrote.

It took a mean 6.4 months (range 1.8-13.7) and a median 4 months (range 2.0-8.7) for patients to receive a diagnosis of CRC after signs and symptoms first occurred.

"Delayed diagnosis may be a result of late patient presentation and lack of clinician knowledge of common CRC symptoms, such as hematochezia or abdominal and pelvic pain, and signs, such as iron deficiency anemia," the authors noted in their introduction. "Patients and clinicians alike may downplay symptom severity and fail to recognize key red flags and clinical cues that should trigger suspicion of CRC."

Reid M. Ness, MD, MPH, of Vanderbilt-Ingram Cancer Center in Nashville, who was not involved in the study, agreed that since these symptoms are so common overall, "they are frequently ignored by providers as trivial."

Hematochezia and unexplained iron deficiency anemia in particular, however, "should always generate a colonoscopy request if one has not been performed very recently," Ness said. "Patients with hematochezia must be evaluated for possible underlying colorectal malignancy regardless of age."

In terms of the differential for abdominal pain, Ness described three categories: chronic pain, lasting more than 3 months; acute pain, lasting less than 2 weeks; and subacute pain, lasting 2 weeks to 3 months. "I am most concerned about the patient with subacute pain as a possible indicator of underlying malignancy," he noted.

A challenge of early-onset CRC is a lack of non-invasive screening options as the incidence rises, said Ajay Goel, PhD, of City of Hope in Duarte, California.

"More and more people are getting this disease when they're in their 20s, 30s and 40s, and screening doesn't even begin until 45," at which point compliance with colonoscopies is poor, Goel told MedPage Today . "For this particular clinical challenge, we basically need better tests -- inexpensive, non-invasive tests we can start running on people much younger than age 45 if we're to tackle this issue."

Of note, an FDA panel on Thursday endorsed a blood-based test for CRC screening in adults 45 years and older at average risk for the disease, despite concerns over the test's low sensitivity for precancerous lesions.

Demb and team used PubMed/Medline, Embase, the Cumulative Index to Nursing & Allied Health, and Web of Science from the start of each database through May 2023 to find any studies reporting on signs and symptoms of CRC in patients younger than 50 who were ultimately diagnosed with non-hereditary CRC. Outcomes of interest included pooled proportions of the signs and symptoms in patients with early-onset CRC; estimates for associations between each sign or symptom and risk of CRC; and the time from sign or symptom presentation to diagnosis.

Among 12,859 studies initially identified, the authors included 81 studies with a total of 24,908,126 patients. Studies were excluded if they had fewer than 15 patients, had patients younger than 18, or if more than half the study period occurred before 1996, when incidence of early-onset CRC began rising.

Most of the included studies (n=76) were cross-sectional studies, four were case-control studies, and one was a cohort study. They were somewhat evenly distributed between North America, Europe, and Asia/Middle East, with 12 others from Africa, South America, and Oceania combined. Most of the studies (83%) were determined to have low risk of bias.

Among the 78 studies that reported on 17 signs and symptoms at presentation, the three most commonly presenting signs/symptoms of hematochezia, abdominal pain, and changes in bowel habits, such as constipation, diarrhea, alternating bowel habits, or alternating diarrhea or constipation, remained the top three both in the U.S. and in other countries and in the studies with populations both 50 and younger and 40 and younger.

Loss of appetite and obstruction were the only common symptoms in the studies with moderate or high risk of bias.

Demb and colleagues said that there was significant heterogeneity across the included studies, which affected their ability to meta-analyze some of the results. "This was most significant in assessment of the associations of signs and symptoms with early-onset CRC, where a lack of a consistent comparator group hindered our ability to pool estimates for the associations," they wrote.

In addition, they were unable to compare early-onset CRC risk against other potential outcomes, "which might have better contextualized the relative risk," they noted.

Tara Haelle is an independent health/science journalist based near Dallas, Texas. She has more than 15 years of experience covering a range of medical topics and conferences. Follow

Disclosures

Demb reported no conflicts of interest.

One co-author reported receiving grants from the National Institutes of Health, American Cancer Society, Pfizer, Dalton Family Foundation, and ACPMP Research Foundation, and personal fees from MJH Life Sciences. Another co-author reported receiving personal fees from Guardant Health, Universal Diagnostics, Geneoscopy, and InterVenn Biosciences, and owning stock in CellMax Life.

Primary Source

JAMA Network Open

Source Reference: Demb J, et al "Red flag signs and symptoms for patients with early-onset colorectal cancer: a systematic review and meta-analysis" JAMA Netw Open 2024; DOI: 10.1001/jamanetworkopen.2024.13157.