Based on the information provided: - This study aims to determine whether early operation and age affect outcomes of ASBO in pediatric patients, so it falls under the category of prognosis. - The study design is a retrospective chart review, which is considered a cohort study. This fits with a level 2b level of evidence according to the Oxford Centre for Evidence-Based Medicine. - A few limitations are noted - the retrospective design, incomplete data, inability to determine why surgeons made clinical decisions. However, overall it seems like a reasonably well-conducted study to address the research question. - The results suggest that delaying operation beyond 48 hours and younger age (under 1 year) are associated with worse outcomes like more bowel

1. Journal Article Reading
Utami Adma Negara

2. Introduction
• ASBO is a known complication after abdominal surgery in pediatric patients
• incidence : 1.1 - 8.3%.
• NOM is generally attempted first, consisting of :
• Nasogastric decompression
• Fluid resuscitation
• Correction of electrolyte imbalances.
• The success rate of NOM in adults ranging from 40% - 73%.
• In children, been reported as low as 0%-16% / as high as 52%-75% and operation is often required
in most cases.
• Urgent operation is considered in : high-grade obstruction, closed-loop obstruction (segmental
volvulus) / suspicion for bowel ischemia.
• Complications of delayed operative management : bowel loss, short gut syndrome, and bowel
perforation, which could lead to sepsis and associated morbidity and mortality.
• The optimal timing of operation to avoid bowel loss varies in the literature for both adult and
pediatric patients from “delayed” considered as short as 5.4 h to 12 and 16 h.

3. Intro..
• There is no clear consensus regarding differences in management of
ASBO based on patient age or other risk factors.
• There is some evidence to suggest that younger patients are more
likely to fail NOM.
• The purpose of our study : to determine whether early operation and
age affect outcomes of ASBO in pediatric patients.
• Hypothesize :
• In cases that fail NOM, early operation results in less bowel loss.
• Younger patients are more likely to fail NOM.

4. Material and methods
• A retrospective chart review of all infants and children aged 18 y or
younger who were treated at an academic tertiary children’s hospital for
ASBO between January 2011 and December 2015.
• Resulted in over 1000 cases.
• Inclusion criteria of abdominal surgery occurring four or more weeks
before the episode of ASBO
• Exclusion criteria :
• hospital admission for primary (not adhesive) bowel obstruction, which included
midgut volvulus or intestinal atresia
• age greater than 18 y
• complex medical diagnoses such as genetic or metabolic syndromes.

5. Material and methods
• Collected data :
• age at presentation
• age at primary abdominal surgery
• gender
• type of management,
• abdominal pain
• temperature and WBC count
• imaging findings
• length of hospital stay.
• Management :
1. urgent operation (without a nonoperative trial)
2. failure of NOM : time-to-operation thresholds of 12, 24, and 48 h
3. successful NOM.

6. Statistical Analysis
• Categorical data using c2 test or Fisher’s exact test
• Numerical data using Student’s t-test or one-way
analysis
• A P-value less than 0.05 was considered
statistically significant.

7. Results
• Median time to surgery :
• Urgent operative group was
1.5 h
• Failure of NOM group was
34.1 h
• The median LOS :
• Failure of NOM group (11.5 d)
• Urgent operative group (7.6
d)
• Successful NOM group (4.7 d)

8. Imaging Findings
• 96.5% had at least one abdominal radiograph.
• CT scan in 83 (32.2%) and small-bowel follow-through in 7 (2.7%)
cases.
• Three cases (1.2%) were taken urgently to the operating room based
on history and clinical picture alone without any initial imaging, and
three cases (1.2%) only had a CT scan in the ER (all had urgent
operation).
• There were five patients in the failure of NOM group with closed-loop
obstruction who did not have early surgery within 12 h because
additional imaging that confirmed the diagnosis of closed-loop
obstruction occurred late (10-18 h after admission to ER).

9. Operative Findings

10. Factor associated with need for operation

11. Discussion
• When children are admitted for ASBO, patients suspected of bowel ischemia / at high-
risk for bowel ischemia based on clinical findings (peritonitis, leukocytosis) and
radiographic (free air, pneumatosis, closed loop obstruction) are taken to the operating
room without a trial of NOM.
• The rest are generally given a trial of NOM.
• The decision to proceed to surgery based on worsening findings on clinical examination :
• increased abdominal pain or tenderness
• imaging : progressive or persistent obstruction, or
• simply a failure of resolution of obstruction
• There are no standardized guidelines for imaging or clinical decision making regarding
timing of operation.
• Our main hypothesis :
• Delay in operation leads to more bowel loss,
• Young age is associated with higher failure of NOM

12. • Feigin et al.2 reported a 31% small bowel resection rate who were taken to the
operating room 16 h after presentation.
• They recommended 48 h as a timepoint of surgical decision making  bowel strangulation
after 48 h.
• Lautz et al. showed similar results with the rate of bowel resection increasing as
time to operation increased.
• they recommended a decision about surgery be made in a patient who has reached 48 h of
NOM.
• Our results showed : delaying operation by >48h  higher need for bowel
resection.
• We recommend that in patients who do not show clinical improvement, the
decision for surgery should be made in a timely fashion so that operation occurs
within 48 h of presentation.
• Children <1 y of age required operation almost 80% and 3.7 times more often
than older children.
• Other authors recommended that children 1-2 y of age undergo a trial of NOM
for 24-48 h and children older than 1-2 y undergo 48 h of NOM to limit bowel
ischemia.

14. • Fever was the only factor that predisposed to needing urgent
operation
• The NOM success rate of 54%
• Stewardson et al demonstrated that 90% of adults with small bowel
obstruction and resulting gangrenous bowel exhibited two or more of
four “classic” findings: leukocytosis, fever, tachycardia, and localized
tenderness.
• Eeson et al.10 evaluated the association of these factors with the
need for surgery, and only leukocytosis and fever were predictive of a
need for immediate surgery.

15. • Closed-loop obstruction cannot resolve without operation, and bowel
ischemia cannot be decompressed via gastric drainage  early
operation, and additional imaging CT or small- bowel follow-through
• The major limitation of this study is :
• retrospective design
• incomplete data
• cannot provide accurate insight on why surgeons made clinical decisions
regarding operative timing

16. Conclusion
• In pediatric patients with ASBO, NOM can be successful, but children
younger than 1 y of age are more likely to require operation.
• Delaying operation more than 48 h may lead to more bowel loss.

17. THANK YOU

18. CAT
(Critical Appraisal of the Topics)

19. Screen for Initial Validity and Relevance
1. Is the article from a peer-reviewed journal ? Yes, from Journal of Surgical
Research
2. Is the location of the study similar to mine so that the results, if valid,
would apply to my practice ? Yes
3. Is the study sponsored by an organization that might influence the study
design or results ? No sponsor
4. Will this information, if true, have a direct impact on the health of my
patients, and is it something they will care about ? Yes
5. Is the problem addressed one that is common to my practice, and is the
intervention or test feasible and available to me ? Yes
6. Will this information, if true, require me to change my current practice ?
Yes

20. Determine the Intent of the Article
Why the study was performed?
• to determine whether early operation and age affect outcomes of ASBO in
pediatric patients
• Four major clinical categories
• Therapy
• Diagnosis
• Causation
• Prognosis

21. Clinical
category
Description Preferred Study
Design
Therapy Tests the effectiveness of a
treatment, such as a drug, surgical
procedure, or other intervention
Randomized, double-
blinded, placebo-
controlled trial
Diagnosis Measures the validity (is it
dependable?) and reliability (will the
same results be obtained every
time?) of a diagnostic test, or
evaluates the effectiveness of a test
in detecting disease at a pre
symptomatic stage when applied to
a large population
Cross-sectional survey
(comparing the new test
with a reference
standard)
Causation Assesses whether a substance is
related to the development of an
illness or condition
Cohort or case-control
Prognosis Determines the outcome of a
disease
Longitudinal cohort
study

22. Evaluate the Validity of the Article Based on Its
Intent
• Therapy
• Diagnosis
• Causation
• Prognosis

23. Level of Evidence
Level Therapy/Prevention,
Aetiology/Harm
Prognosis Diagnosis
1a SR (with homogeneity*)
of RCTs
SR (with homogeneity*)
of inception cohort
studies; CDR†
validated in
different
populations
SR (with homogeneity*) of
Level 1 diagnostic
studies; CDR† with 1b
studies from different
clinical centres
1b Individual RCT (with
narrow Confidence
Interval‡)
Individual inception
cohort study with >
80% follow-up;
CDR† validated in a
single population
Validating** cohort study
with good††† reference
standards; or CDR†
tested within one
clinical centre
1c All or none§ All or none case-series Absolute SpPins and
SnNouts††

24. Level Therapy/Prevention,
Aetiology/Harm
Prognosis Diagnosis
2a SR (with homogeneity* ) of
cohort studies
SR (with homogeneity*) of
either retrospective cohort
studies or untreated
control groups in RCTs
SR (with homogeneity*) of
Level >2 diagnostic studies
2b Individual cohort study
(including low quality RCT;
e.g., <80% follow-up)
Retrospective cohort
study or follow-up of
untreated control patients
in an RCT; Derivation of
CDR† or validated on
split-sample§§§ only
Exploratory** cohort study with
good†††reference standards;
CDR† after derivation, or
validated only on split-
sample§§§ or databases
2c "Outcomes" Research;
Ecological studies
"Outcomes" Research
LEVEL OF EVIDENCE

25. Level Therapy/Prevention,
Aetiology/Harm
Prognosis Diagnosis
3a SR (with homogeneity*) of
case-control studies
SR (with homogeneity*) of 3b
and better studies
3b Individual Case-Control
Study
Non-consecutive study; or
without consistently applied
reference standards
4 Case-series (and poor quality
cohort and case-control
studies§§ )
Case-series (and poor
quality prognostic cohort
studies***)
Case-control study, poor or
non-independent reference
standard
5 Expert opinion without
explicit critical appraisal, or
based on physiology, bench
research or "first principles"
Expert opinion without
explicit critical appraisal,
or based on physiology,
bench research or "first
principles"
Expert opinion without explicit
critical appraisal, or based on
physiology, bench research or
"first principles"
LEVEL OF EVIDENCE

26. Grades of Recommendation