From the Guidelines
The Revised Cardiac Risk Index (RCRI) is the most predictive screening tool to assess someone's perioperative risk for a surgical repair of an apple-shaped large bowel obstruction. This is based on the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery, which highlights the RCRI as a simple, validated, and commonly used tool to assess perioperative risk of major cardiac complications 1. The RCRI uses 6 predictors of risk, including history of ischemic heart disease, congestive heart failure, cerebrovascular disease, diabetes mellitus, chronic kidney disease, and high-risk surgery, to estimate the risk of cardiac events in patients undergoing noncardiac surgery.
When evaluating a patient with an apple-shaped large bowel obstruction, it is essential to consider the potential for cardiac complications, as well as other perioperative risks such as respiratory and thromboembolic events. The RCRI can be used in conjunction with other assessment tools, such as the American Society of Anesthesiologists (ASA) Physical Status Classification System and the Duke Activity Status Index (DASI), to provide a comprehensive evaluation of the patient's perioperative risk. However, the RCRI is particularly useful in this context because it specifically addresses cardiac risk, which is a major concern in patients undergoing surgical repair of a bowel obstruction.
Key factors to consider when using the RCRI include:
- History of ischemic heart disease
- Congestive heart failure
- Cerebrovascular disease
- Diabetes mellitus
- Chronic kidney disease
- High-risk surgery By using the RCRI to assess perioperative risk, clinicians can identify patients who may require additional evaluation or intervention to minimize their risk of cardiac complications during surgical repair of an apple-shaped large bowel obstruction, ultimately improving morbidity, mortality, and quality of life outcomes 1.
From the Research
Perioperative Risk Assessment for Surgical Repair of Bowel Obstruction
The most predictive screening tool to assess someone's perioperative risk for a surgical repair of a bowel obstruction is a point-scoring risk calculator, as developed in the study 2. This calculator assigns points based on various preoperative risk variables, including:
- Age: with higher points assigned to older patients
- Disseminated cancer: 2 points
- American Society of Anesthesiology (ASA) score of 4 or 5: 1 point
- Preoperative sepsis: 1 point
- Hypoalbuminemia: 1 point
- Fully dependent functional status: 1 point
Predictive Accuracy of the Risk Calculator
The risk calculator showed strong discrimination (c-statistic = 0.825) and good calibration (Brier score = 0.043) in the experimental group, and was successfully translated from individual preoperative variables (c-statistic = 0.840) and externally validated in ACS-NSQIP (c-statistic = 0.827) 2. The calculator can effectively discriminate major surgical complications, including:
- Major adverse cardiovascular events
- Cardiac complications
- Stroke
- Pulmonary complications
- Renal complications
- Bleeding
- Sepsis
Diagnosis and Management of Bowel Obstruction
Diagnosis of bowel obstruction typically requires imaging, with computed tomography and ultrasound being reliable diagnostic methods 3. Management includes intravenous fluid resuscitation, analgesia, and determining the need for operative vs. nonoperative therapy 3. Nasogastric tube is useful for patients with significant distension and vomiting 3. Surgery is needed for strangulation and those that fail nonoperative therapy 3.
Surgical Intervention for Large Bowel Obstruction
The surgical management of large bowel obstruction is heterogeneous and influenced by multiple variables, with the most common operation being fecal diversion without resection 4. The management of large bowel obstruction entails high operative and stoma rates, with less than 30% of patients undergoing stoma closure 4. Resection, anastomosis, and diverting loop ileostomy had the highest chance of stoma reversal 4.
Evaluation and Management of Intestinal Obstruction
Acute intestinal obstruction occurs when the forward flow of intestinal contents is interrupted or impaired by a mechanical cause, with the most common causes being intra-abdominal adhesions, malignancy, and herniation 5. Management of uncomplicated obstructions includes intravenous fluid resuscitation, nasogastric decompression, and bowel rest 5. Patients with fever and leukocytosis should receive antibiotic coverage against gram-negative organisms and anaerobes 5. Evidence of vascular compromise or perforation, or failure to resolve with adequate nonoperative management is an indication for surgical intervention 5.