Research Article
Clinical Outcome of Patients Submitted to Resection of the Small Bowel Segments
Marina GF Lopes1,2†, Thaís C Duarte1,2†, Janser M Pereira3, Lorena A Freitas1 and Daurea A De-Souza1,2*
1Faculty of Medicine, Federal University of Uberlândia, Brazil
2Postgraduate Program in Health Sciences, Federal University of Uberlândia, Brazil
3Faculty of Mathematics, Federal University of Uberlândia, Brazil
†First co-authors of this article
*Corresponding author: Daurea A De-Souza, Internal Medicine Department, Faculty of Medicine, Federal University of Uberlândia, Av. P ará, 1720, Bloco 2H, sala 1, Campus Umuarama, CEP 38400-320, Uberlândia-MG, Brazil
Published: 10 Aug, 2018
Cite this article as: Lopes MGF, Duarte TC, Pereira JM,
Freitas LA, De-Souza DA. Clinical
Outcome of Patients Submitted
to Resection of the Small Bowel
Segments. Clin Surg. 2018; 3: 2061.
Abstract
Background: Segments of the digestive tract have specificities of nutrient absorption. The objective
of this study was to identify factors related to the prognosis of patients submitted to bowel resections
at a university hospital.
Materials and Methods: A cross sectional, retrospective study, using a specific semi-structured
form. An analysis was made of 169 patient records all submitted to bowel resection during the
period of August/2007 to July/2013. To perform data analysis, the patients were grouped according
to their clinical evolution (hospital discharge/death).
Results: Longer length of hospital stay and age over 60 years old were associated with a higher
mortality rate. Among patients submitted to single (n=148) or multiple (n=21) enterectomy, the
mortality rate was 33.8% (n=50 deaths) and 52.4% (n=11 deaths), respectively. Hospital discharge
was more common among patients undergoing a single enterectomy (p=0.143). Among patients
submitted to single bowel resection, non-description of resected bowel segments increased the
mortality rate (p=0.002). Remaining small intestine description was performed for 14 patients, and
11 of these patients met the diagnosis criteria for short bowel syndrome (SBS) (78.6%). SBS patients
had a 90.9% mortality rate. For most enterectomized patients, no nutritional status assessment was
performed (n=103, 60.9%). Patients classified as malnourished (n=19; 52.8%) had a higher mortality
rate (p=0.032).
Conclusion: The lack of description of the resected and/or remaining intestinal segments, as well
as the non-evaluation of the nutritional status, contributed to the higher mortality rate of patients
submitted to resection of bowel segments.
Keywords: Bowel resection; Bowel segments; Short bowel syndrome; Clinical outcome; Malnutrition; Mortality rate
Introduction
The small intestine is a component of the lower gastrointestinal tract, which is divided into the
segments duodenum, jejunum and ileum. The normal length of the small bowel varies between 300
cm to 800 cm, tending to be a little smaller in women [1]. The absorption capacity of the small bowel
is amplified sharply by multiple small folds of the mucosa, which characterize the small intestine as
the main anatomical structure responsible for the absorption of nutrients [2].
Although there is no consensus between the different researchers concerning the specific location
and the bowel segment responsible for the absorption of each nutrient, some nutrients are absorbed
almost totally in the first 150 cm of the small bowel [2,3]. More recently, it has been reported that
there is an anatomical absorption gradient between the different segments of the small bowel, that
is, the absorption of some specific nutrients is greater in the duodenum and in the proximal jejunum
than in the ileum [4]. In contrast, the vitamins, minerals and fluids are absorbed simultaneously
across the different anatomical segments of the digestive tract [1]. In the large intestine, there occurs
the absorption of water and electrolytes still present in intraluminal content [5].
Bowel resection is indicated for surgical treatment in various diseases of the small and/or large
intestine, including cancer, bowel obstruction, chronic inflammatory
bowel disease, mesenteric ischemia, trauma injuries, among other
clinical conditions [6]. Due to the severity of the underlying disease,
there frequently occurs superposition of the clinical manifestations
associated with the etiologic factor and intestinal resection [7].
Some researchers have identified that a longer survival rate can be
expected for patients submitted to a single and more conservative
bowel resection [7]. The single extensive and the multiple small bowel
resections, frequently induce severe pathophysiological alterations,
including depletion in the nutritional status, with a consequential
increase in morbidity and mortality rate [8].
The principal clinical-surgical manifestations identified during
the immediate and/or late post-operatory periods are diarrheal
episodes both frequent and voluminous, with the presence of food
debris, steatorrhea, hydroelectrolytic unbalance, and renal function
impairment [1,9]. Among those patients submitted to resection of
intestinal segments, the precocious impairment of the nutritional
status predispose them to dehiscence of anastomoses, development
of fistulae and a recurrent infectious diseases [4,9,10]. In addition,
patients submitted to resection of bowel segments present an increase
in gastric secretion, which predisposes the patient to the development
of acid-peptic diseases [1,11].
The occurrence of bacterial overgrowth, deficiencies in macro
and micronutrients, as well as varied degrees of insufficiency or even
intestinal failure are late complications frequently identified in the
clinical practice. Patients who present acute diarrhoea associated with
severe fluid and electrolyte instability, the use of complementary or
exclusive parenteral nutrition is indicated over prolonged periods or
even indefinitely [11,12].
The information that refers to the new anatomic structure of the
gastrointestinal tract and the description of the absence of diseases
in the wall of the remaining intestine are essential to the evaluation
concerning the degree of functional impairment in the digestive tract
over the post-operative period [13,14]. In addition, description of
the type/length of the remaining small intestine, measured during
the intraoperative period, as well as the type/length of the resected
intestine, are essential [14]. The aim of the present study was to
identify factors related to the prognosis among patients submitted to
intestinal resection at a university hospital.
Material and Methods
The design of the present study is of the cross sectional,
retrospective type. The study was approved by the research ethics
committee on human subjects of the Federal University of Uberlândia,
MG, Brazil.
An analysis was made of the medical records of patients of ≥ 20
years, submitted to resection of small bowel segments over the period
of August 2007 to July 2013, at the Clinical Hospital of the University.
The medical records of 240 individuals that met the search criteria
provided to the Statistics Sector were found. Among the medical
records found in the Medical Archive Sector (n=217), medical
records of 37 patients who were discharged from hospital and 11
patients who died were excluded. More specifically, the records
excluded were those that presented exclusive intestinal raffia (n=4, all
the patients received hospital discharge); exclusive colectomy (n=32,
26 patients received hospital discharge); partial or total gastrectomy
(n=10, where 7 patients received hospital discharge); and records
containing inconsistent data (n=2, all patients died). The final study
sample was made from the records of 169 patients who had some type
of enterectomy, and received hospital discharge (n=108) or evolved
to death (n=61).
The collection of data was performed using a specific semistructured
form. In order to analyse the information presented on
the records, the patients were grouped according to their clinical
evolution (hospital discharge/death). To characterize the sample,
information was collected concerning gender, age and length of
hospital stay of the patients.
In relation to the characteristics of bowel resection, information
was collected that referred to the number and the etiological factor
of enterectomy; to the length and segment type of the resected and
remaining small intestine; to the team that described the length
and segment type of the resected and remaining small bowel; to the
diagnosis of short bowel syndrome; and to the performing or not
of colectomy associated with enterectomy. In order to facilitate the
analysis of the data, the identified etiological factors were grouped
according to their main etiological and clinical characteristics.
In order to analyse the data related to bowel resection, the
lengths of the small bowel segments described in the literature for
healthy individuals were used. In this manner, for the jejunum and
ileum segments lengths of 100 cm to 300 cm and 150 cm to 400
cm, respectively, were used [1,5]. Then, in order to allow for a more
detailed analysis of the data, tables with partial value ranges of the
jejunum and ileum lengths were constructed.
In order to evaluate the nutritional status, all the information
described in the records that referred to the nutritional status before
the enterectomy was collected. In this evaluation, any anthropometric
parameter that allowed for the classification of the nutritional status
was considered valid. In addition, on those records that contained
body weight and height descriptions, the Body Mass Index (BMI)
was calculated. The adult and senior citizen patients were classified
according to the criteria established by WHO [15] and Lipschitz [16],
respectively. Considered also were the classification of the Subjective
Global Assessment (SGA) [17] and the percentage of weight loss
(%WL) [18].
Statistical analyses
To characterize the sample, average and standard deviation,
medians, and proportions were estimated. For the comparison
of two or more proportions, the chi-squared test of asymptotic
multiple comparisons of binomial proportions was used. This test
was applied to relate the clinical outcome presented by the patients
(hospital discharge/death) to the gender, the number of enterectomy,
the description of the etiologic factor of the enterectomy, and to the
length and segment type of the resected and remaining small bowel.
The chi-squared test was also used to verify the relationship between
the nutritional state prior to the bowel resection and the clinical
evolution. For the analysis of the relationship between age groups and
prognosis, the Spearman linear correlation test was used. In all the
analyses, a significance of p ≤ 0.05 was considered. The analyses were
performed using the freeware R.
Results
Among the 169 medical records analyzed, the performing of an
enterectomy was more frequent among male patients (n=94, p=0.039).
A positive association was identified between the increase in age and
mortality rate p<0.001, i.e., patients over 60 years old submitted to an
enterectomy presented a worse prognosis than younger patients. The
median for the length of hospital stay was higher among patients that
evolved to death than those patients that received hospital discharge
(20.0 days vs. 8.0 days, respectively; p=0.001) (Table 1).
Among those patients submitted to a single (n=148) or multiple
(n=21) enterectomy, the mortality rate was equal to 33.8% (n=50
deaths) and to 52.4% (n=11 deaths), respectively. Hospital discharge
was more common among patients undergoing single enterectomy
than those patients undergoing multiple enterectomy (p=0.143)
(Table 1).
The main etiological factors for the performing of an enterectomy
were malignant neoplasm (n=39; 23.1%), trauma (n=35; 20.7%),
and intestinal obstruction (n=28; 16.6%). Among those patients that
evolved to death, the most frequent etiological factors for enterectomy
were malignant neoplasm (n=17; 27.9%); intestinal obstruction (n=11;
18.0%) and vascular ischemia (n=11; 18.0%). For those patients that
received hospital discharge, the most frequent etiological factors for
enterectomy were trauma (n=26; 24.1%); malignant neoplasia (n=22;
20.3%) and intestinal obstruction (n=17; 15.7%). Patients diagnosed
with vascular ischemia presented a higher mortality rate (n=11; 18.3%
of deaths; p<0.001) (Table 2).
Among the patients submitted to a single enterectomy (n=148),
the description of the type of bowel segment resected was performed
for 88 patients (59.5%). A mortality rate of 23.9% and of 48.3% was
identified for patients with and without description of the type of the
bowel segment resected, respectively (Figure 1A and 1B). In relation
to the clinical evolution of patients submitted to a single enterectomy,
the description of the bowel segment was identified as a factor directly
related to the prognosis. More specifically, among the patients with
hospital discharge (n=98), it was identified that 67 patients (69.4%)
presented a description of the bowel resection segment (p=0.002).
Among the patients that evolved to death (n=50), it was identified that
29 of the patients (58.0%) did not present a description of the bowel
resection segment (p=0.002) (Figure 1A and 1B). The description of
the bowel resection length was identified for 129 patients (87.2%), all
submitted to a single enterectomy (Figure 1C and 1D). There was no
difference in the mortality rate among patients with (n=44; 34.1%)
and without (n=6; 31.6%) description of the resected bowel length,
respectively (p=0.828) (Figure 1C and 1D).
Among the patients submitted to a single bowel resection (n=148;
98 patients with hospital discharge and 50 patients evolved to death),
43 patients (29.1%) presented a description of the segment and/
or length of the bowel resection only through the surgical team,
and 51 patients (34.5%) presented a description only through the
anatomy pathological team. The mortality rate was higher (p=0.006)
among those patients submitted to a single enterectomy which had
a description of the segment and/or bowel resection length made
exclusively through pathology (n=19; 37.3%). Among the 48 patients
that had exclusively the description of the bowel resected length, the
proportion of patients evolved to death (n=23; 46.0% of deaths) was
higher than the proportion of patients that received hospital discharge
(n=25; 25.5% of discharges) (p=0.012) (Table 3).
Among the patients submitted to multiple enterectomy (n=21),
there were no identifications made in the medical records to
descriptions of the segment and the bowel resected length, in at least
one of the surgical procedures, for 20 patients (95.2%) and for 8
patients (38.1%), respectively (Table 4).
The description of the remaining small bowel was performed
for 14 patients submitted to resection of bowel segments, with 12
patients being submitted to a single enterectomy. The diagnosis of
short bowel syndrome [1] was performed for 11 patients (78.6%) that
had a description of the remaining small bowel. Among the patients
diagnosed as suffering from short bowel syndrome, the mortality rate
was of 90.9% (n=10) (Table 5).
None of the methods used for nutritional status assessment
were identified in 103 of the analyzed medical records (60.9%) of
patients submitted to resection of small bowel segments. Among the
66 medical records that presented at least one method that allowed
for the evaluation of the nutritional status, 36 patients (54.5%) were
classified as malnourished. There was no difference in the mortality
rate of patients submitted to resection of bowel segments in relation
to the evaluation of the nutritional status [27 deaths (44.3%) among
the evaluated patients vs. 34 deaths (55.7%) among patients not
evaluated; p=0.205]. The mortality rate was higher (p=0.032) among
the patients classified as malnourished (n=19; 52.8%) than among
those not classified as malnourished (n=8; 26.6%) (Table 6).
Figure 1
Figure 1
Distribution of patients submitted to single enterectomy, according to the description of the segment and the length of resected small intestine (n=148).
Table 1
Table 2
Table 3
Table 3
Distribution of patients submitted to single enterectomy (n=148), according to the segment description and the length of the resected small bowel.
Table 4
Table 4
Distribution of patients submitted to multiple enterectomy (n=21), according to the description of the segment and the length of the resected small intestine.
Table 5
Table 5
Clinical evolution of patients submitted to enterectomy, according to the description of the remaining small bowel (n=14).
Discussion
In the present study, an analysis was made of medical records of
patients submitted to small bowel resection surgery during the period
of August 2007 to July 2013. On a majority of the analyzed medical
records, identification was made as to the patients being submitted to
single bowel resection. Patients over 60 years of age and with a higher
length of hospital stay presented a poor prognosis. The etiological
factor of mesenteric vascular ischemia, showed a higher mortality
rate.
Among those patients submitted to a single enterectomy, the
description of the bowel resection length was more frequent than
the description of the bowel resection segment (87.2% vs. 59.5%,
respectively). Among the patients submitted to a single enterectomy,
the lack of description for of the bowel resection segment was directly
associated with the increase in mortality rate (p=0.002). There was no
association made between lack of description of the bowel resection
length and the mortality rate.
In the analysis of the association between lack of description of
the bowel segment and increase in mortality rate, it is necessary to
consider that the absorption of nutrients, as well as some essential
functions in the digestive/absorptive process occur at specific
locations of the digestive tract [4,19]. As for example, the ileum is the
bowel segment responsible for absorbing vitamin B12, and takes on
the main role in the enterohepatic cycle, performing the reabsorption
of bile salts [20,21]. One additional and relevant aspect is that the
ileum is the bowel segment that presents the highest adaptive capacity
after the performing of bowel resection [19]. In this way, although the
absorption of nutrients occurs mainly in the proximal small bowel,
those patients submitted to resection of ileus segments present higher
hemodynamic instability and greater impairment of nutritional
status [4,20-22]. In addition, in clinical practice the lack of knowledge
concerning the bowel resection segment, limits the performance of
health team professionals, especially in relation to the establishment
of a therapeutic plan that best attends to the needs of each patient.
More recently, the importance of the diagnosis of intestinal
insufficiency/failure has been reported [12], that is, in the clinical
practice it is essential to identify the degree of bowel autonomy that
the patient presents [4,19,23]. Thus, it is of great concern to identify
that the description of the remaining small intestine was performed
in only 8.3% of the medical records analyzed. The lack of knowledge
regarding the degree of intestinal autonomy of a patient makes it
difficult to implement more individualized and effective dietary
conducts, which impairs the recovery/maintenance of a normal
nutritional status, as well as the development of bowel adaptation
[24,25].
The description of the remaining small bowel allows for the
performing a short bowel syndrome diagnosis. In the present study,
11 patients met the criteria established for the diagnosis of short
bowel syndrome [1]. Among these patients, the mortality rate was
90.9%. The high mortality rate among these patients diagnosed
with short bowel syndrome is frequently associated with intestinal
insufficiency/failure, characterized by diarrheic episodes frequent
and voluminous, associated with a severe hemodynamic instability
and impairment of the renal function [10]. For patients with short
bowel syndrome it is common to become temporarily or permanently
dependent on total or complementary parenteral nutrition. In this
clinical situation, the patients are exposed to the complications
inherent to the use of the intravenous route for diet administration
[26]. The treatment of patients diagnosed with short bowel syndrome
needs to be individualized, aiming at the development of intestinal
adaptation, clinical-nutritional stability and the improvement in life
quality [26].
On a majority of the analyzed medical records, no identification
was made concerning any method that evaluates the nutritional
status, including screening tests, or even body weight and/or height
measurements. Among the patients that had nutritional status
assessment, 54.5% were classified as malnourished. The evaluation
of the nutritional status is an essential procedure for predicting
nutritional risks and establishing adequate nutritional therapy,
especially for those patients exposed to metabolic stress [27]. Among
the patients submitted to enterectomy, the failure to carry out the
nutritional status assessment is a conduct, at least questionable,
since it neglects the current clinical-nutritional condition, as well
as allows the greater commitment of protein-energy malnutrition.
Malnourished patients present an increase in the frequency of
infectious and non-infectious complications, the length of hospital
stay, the costs of hospitalization, as well as higher mortality rate [28].
Table 6
Conclusion
In the present study, it was demonstrated that the non-description of the resected and/or remnant bowel segments contributed to an increase in the mortality rate among patients submitted to enterectomy. Although the evaluation of the nutritional status of patients submitted to resection of intestinal segments was rarely performed, patients classified as malnourished had a high mortality rate. The results presented in the present study illustrate the need to establish protocols of conducts for the perioperative and postoperative periods of patients submitted to resection of small bowel segments. In addition, in order to reduce the morbidity and mortality of patients undergoing an enterectomy, it is essential the performance of a multiprofessional team, with emphasis on the diagnosis of nutritional status and the implementation of individualized dietary therapies adapted to the current clinical situation of the patient.
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