Laparoscopic management of adhesive small bowel obstruction

Adhesions from prior surgery are the most common cause of small bowel obstruction (SBO) in the Western world. Although laparoscopic adhesiolysis can be performed safely and effectively, the indications and contraindications to the use of laparoscopic techniques in SBO are not clearly defined. The goal of our study was to determine the outcomes of the laparoscopic approach to SBO and discuss patient considerations for its utilization. We retrospectively surveyed all patients undergoing laparoscopic or attempted laparoscopic adhesiolysis performed by the authors between July 1997 and March 2006. Data obtained included patient demographics, clinical and radiologic presentation, and intraoperative and postoperative course. Thirty-three patients underwent laparoscopic adhesiolysis secondary to a SBO. Mean age was 53.6 years (range, 29-84 years) and 64 per cent (21 of 33) were female. Mean body mass index was 30.0 kg/m2 (range, 22.6-46.1 kg/m2). Thirty-one patients (93.9%) had undergone between one and four abdominal surgeries and seven (21.2%) had a previous episode of SBO. There were no patients with peritonitis. Abdominal CT scan was performed preoperatively in 27 patients (81.8%). Laparoscopy diagnosed the site of obstruction in all patients. Twenty-nine patients (88%) were successfully treated laparoscopically. Conversion to laparotomy was required in four cases as a result of dense adhesions and/or a lack of working space. Mean procedural time was 101 minutes (range, 19-198 minutes). There was one intraoperative complication (enterotomy), which was repaired laparoscopically and did not require conversion. Conversion was associated with significantly increased procedural time (129 versus 93 minutes; P = 0.02), but not blood loss or complications. Average times to passage of flatus and first bowel movement were 2.3 days (range, 0.5-5 days) and 3.2 days (range, 1-6 days), respectively. Seven patients (21.2%) had postoperative complications, including wound infection, urinary tract infection, and acute renal insufficiency, all of which occurred in patients completed laparoscopically. One patient had a recurrent SBO 8 months postoperatively managed by repeat laparoscopic lysis of adhesions. Mean postoperative stay was 6 days (range, 1-19 days). There was no hospital mortality. Laparoscopy is safe and feasible in the management of acute SBO in selected patients. It is an excellent diagnostic tool and is therapeutic in most cases.     

Single-port laparoscopic management of adhesive small bowel obstruction

Laparoscopic adhesiolysis has been the focus of much recent attention; however, the role of single-port laparoscopic surgery for adhesive small bowel obstruction remains unclear. We report our experience of performing single-port laparoscopic surgery for adhesive small bowel obstruction through a retrospective review of 15 consecutive patients who underwent single-port laparoscopic surgery for single adhesive small bowel obstruction between 2010 and 2012. We analyzed data on patient demographics, operating time, conversion, and surgical morbidity. Surgery was completed successfully without conversion to laparotomy or the need for additional intraoperative ports in 14 patients, but the remaining patient had peritoneal dissemination from colon cancer. The median operative time was 49 (25–148) min, and the estimated blood loss was 19 (2–182) ml. There were no major postoperative complications. We conclude that single-port laparoscopic surgery is a technically feasible approach for selected patients with adhesive small bowel obstruction when preoperative imaging identifies a single adhesive obstruction.     

Recurrent adhesive small bowel obstruction

Adhesive obstruction of the small bowel complicates about 5% of laparotomies; of these, 5–10% have recurrent attacks. The etiology of adhesions is incompletely understood and attempts to prevent their formation are of unproven value. Patients with recurrent acute obstruction that threatens strangulation, or that fails to subside, require laparotomy. If numerous adhesions have to be divided, it is worth considering a procedure to encourage fresh adhesions to form in a favorable pattern. Suture plication of the bowel by Noble's technique has a high incidence of complications and recurrent obstruction, and transmesenteric plication cannot be used in the presence of sepsis. Splinting of the entire small bowel by intraoperative passage of a long tube, which is left indwelling for 2–3 weeks, appears to be effective and safe. We have used this method in 140 patients without associated complications; of these, 17 had recurrent intestinal obstruction after 1–5 previous laparotomies for adhesions. A meticulous adhesiolysis followed by transluminal splinting through a jejunostomy has been followed by freedom from recurrence during 103 patient-years of follow-up.

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Resumen La obstrucción por adherencias es una complicación que ocurre en alrededor del 5% de las laparotomías, y de los pacientes que la desarrollan 5–10% sufren episodios recurrentes. La etiología de las adherencia no es totalmente conocida, y los intentos orientados a prevenir su formación han probado ser de utilidad no comprobada. Los pacientes con obstrucción aguda que presagia estrangulación o que no cede con un manejo de unos días de reposo intestinal y líquidos parenterales, requieren laparotomía. Cuando es necesario dividir numerosas adherencias, es Útil considerar la realización de un procedimiento que promueva la formación de adherencias frescas en un patrón ordenado y favorable. La plicación mediante suturas segÚn la técnica de Noble se acompaña de una elevada tasa de complicaciones y de obstrucción recurrente, y la plicación transmesentérica está contraindicada en presencia de sepsis. La fijación de la totalidad del intestino delgado mediante la colocación intraoperatoria de un tubo intestinal largo, el cual es dejado por 2–3 semanas, parece ser un método efectivo y seguro. Hemos utilizado tal método en 140 pacientes sin complicaciones; de éstos, 17 presentaban obstrucción recurrente después de 1–5 laparotomías previas por adherencias. La meticulosa lisis de las adherencias seguida de la fijación transluminal mediante tubo colocado a través de una yeyunostomía a 10–15 cm del ángulo duodenoyeyunal ha resultado en ausencia de recurrencia en 103 pacientes-año de seguimiento.

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Résumé L'occlusion de l'intestin grÊle secondaire à des adhérences complique environ 5% des laparotomies et récidive dans 5–10% des cas. L'étiologie précise des adhérences n'est pas parfaitement connue et toutes les méthodes de prévention qui ont été tentées n'ont pas fait leur preuve. Tous les malades qui présentent des attaques répétées et des menaces d'étranglement intestinal doivent Être opérés. Si les adhérences à lever sont très nombreuses il est nécessaire d'avoir recours à une méthode thérapeutique qui favorise la reconstitution en bon ordre de nouvelles adhérences. La plicature ordonnée des anses intestinales selon la technique de Noble est suivie de nombreuses complications et de récidive, la plicature transmésentérique selon la technique de Child ne peut Être employée en cas d'infection. C'est la raison pour laquelle il convient de substituer à ces modes de plicature, celle qui fait appel à un long tube intradigestif qui est laissé en place 2–3 semaines. La méthode est dénuée de danger et efficace. Elle a été employée chez 140 malades sans aucune complication alors mÊme que 17 d'entre eux présentaient des occlusions à répétition, et avaient subi de l à 5 laparotomies. Cette technique de libération des adhérences suivie de la plicature ordonnée des anses intestinales sur un tube introduit dans le grÊle par la voie d'une petite jéjunostomie a permis d'enregistrer l'absence de récidives de l'occlusion chez 103 malades qui ont été attentivement suivis.

     

The management of adhesive small bowel obstruction - an update

Adhesive small bowel obstruction is a common cause for admission to general surgical wards in developed countries. Recent advances in diagnosis and management include the use of water soluble contrast agents in the treatment and triage of patients to an operative or conservative course, the use of CT scanning in diagnosis, the use of laparoscopy in treatment and antiadhesion techniques to prevent recurrence.     

Early indications of adhesive small bowel obstruction

The clinical symptoms and signs of small bowel obstruction are characteristic and are unlike any type of intra-abdominal disease. The colic is specific in character and different from other forms of abdominal colic. The x-ray is most valuable in confirming the diagnosis of small bowel obstruction, in locating the site of the obstruction and in determining to a large extent the nature of the obstruction.The function of the bowel distal to the obstruction is unimpaired and should adequate function take place it does not indicate the absence of obstruction.The urgency of immediate surgery is emphasized in strangulated obstruction in contrast to the feasibility of delaying surgery in advanced simple obstruction until physiological measures and intubation procedures can be adequately employed.     

Impact of Gastrografin in clinical practice in the management of adhesive small bowel obstruction

Background

Gastrografin (GG) has been shown to accelerate the resolution of adhesive small bowel obstruction (ASBO) and decrease length of stay (LOS) in hospital. Consequently, we instituted a protocol recommending the routine use of GG in patients with ASBO. This study reviews patient outcomes after protocol implementation.

Methods

We conducted a retrospective review of all patients with ASBO from January 1997 to December 2007. Data were categorized by admission date and use of GG. The outcomes reviewed were protocol uptake, median LOS in hospital and operative rate. Results were analyzed using the Mann–Whitney U test and the 2-tailed Fisher exact test.

Results

There were 710 patients with ASBO overall. Sixteen of 376 (4.3%) patients received GG before institution of the protocol (period 1), whereas 195 of 334 (58.4%) received GG thereafter (period 2). In period 2, use of GG was limited to between 58% and 69% of all potentially eligible patients per year. Fifty-seven of 710 (8%) patients required surgery. In period 1, there were no significant differences in median LOS in hospital (p = 0.29) and operative rate (p = 0.65) between patients who received GG and those who were managed without GG. In period 2, patients receiving GG had a greater median LOS in hospital (3 [range 2–5] v. 2 [range 1–5] d, p = 0.048) but significantly lower operative rates (5.1% v. 12.9%, p = 0.018). Overall, the median LOS decreased over time (period 1: 4 [2–7] d v. period 2: 2 [1–5] d, p = 0.010). The operative rate did not vary substantially bewteen periods (7.7% v. 8.4%, p = 0.42).

Conclusion

The introduction of a protocol has increased the proportion of eligible patients receiving GG. However, protocol nonadherence and factors other than GG usage have influenced LOS in hospital and operative rates. Demonstrated benefits from previously published clinical trials have thus not been replicated within our setting.     

Meta-analysis of oral water-soluble contrast agent in the management of adhesive small bowel obstruction

BACKGROUND: Adhesions are the leading cause of small bowel obstruction. Identification of patients who require surgery is difficult. This review analyses the role of Gastrografin as a diagnostic and therapeutic agent in the management of adhesive small bowel obstruction. METHODS: A systematic search of Medline, Embase and Cochrane databases was performed to identify studies of the use of Gastrografin in adhesive small bowel obstruction. Studies that addressed the diagnostic role of water-soluble contrast agent were appraised, and data presented as sensitivity, specificity, and positive and negative likelihood ratios. Results were pooled and a summary receiver-operator characteristic (ROC) curve was constructed. A meta-analysis of the data from six therapeutic studies was performed using the Mantel-Haenszel test and both fixed- and random-effect models. RESULTS: The appearance of water-soluble contrast agent in the colon on an abdominal radiograph within 24 h of its administration predicted resolution of obstruction with a pooled sensitivity of 97 per cent and specificity of 96 per cent. The area under the summary ROC curve was 0.98. Water-soluble contrast agent did not reduce the need for surgical intervention (odds ratio 0.81, P = 0.300), but it did reduce the length of hospital stay for patients who did not require surgery compared with placebo (weighted mean difference--1.84 days; P < 0.001). CONCLUSION: Published data strongly support the use of water-soluble contrast medium as a predictive test for non-operative resolution of adhesive small bowel obstruction. Although Gastrografin does not reduce the need for operation, it appears to shorten the hospital stay for those who do not require surgery.     

Strangulating adhesive small bowel obstruction with normal radiographs

A review of patients having laparotomy for adhesive small bowel obstruction has revealed that many patients have normal radiographs on admission and that this group of patients, who are predominantly women, have delayed laparotomies and are at a significantly increased risk of developing strangulating obstruction while in hospital. The clinical and laboratory data which may distinguish strangulating from non-strangulating obstruction were examined and found to be non-discriminatory in this series.     

Posttraumatic small bowel obstruction in children

Background

The diagnosis of intestinal injuries in children after blunt abdominal trauma can be difficult and delayed. Most children who suffer blunt abdominal trauma are managed nonoperatively, making the diagnosis of intestinal injuries more difficult. We sought to gain information about children who develop intestinal obstruction after blunt abdominal trauma by reviewing our experience.

Methods

Review of records from a pediatric tertiary care center over an 11.5-year period revealed 5 patients who developed small bowel obstruction after blunt trauma to the abdomen. The details of these patients were studied.

Results

All patients were previously managed nonoperatively for blunt abdominal trauma. Intestinal obstruction developed 2 weeks to 1 year (median, 21 days) after the trauma. Abdominal x-ray, computerized tomography scan, or barium meal studies were used to establish the diagnosis. The pathology was either a stricture, an old perforation, or adhesions causing the intestinal obstruction. Laparotomy with resection and anastomosis was curative.

Conclusions

Posttraumatic small bowel obstruction is a clinical entity that needs to be watched for in all patients managed nonoperatively for blunt abdominal trauma.     

Predictive factors and treatment of small bowel adhesive obstruction

Our study is based on a retrospective analysis about a ten years' control on patients with a small bowel adhesive obstruction (SBAO) due to primitive abdominal surgical operations. From the valuation of the obtained data and through a literatures review we tried to better define the best treatment. On 297 admissions of 248 patients with a diagnosis of SBAO 196 operations were performed, which indication was based on every clinical data, haematologic and radiologic examinations. Moreover, it was analysed the responsive factor that caused adhesions with a careful valuation of the primitive surgical operation and the possibility of recurrences. From this study it is evicted that SBAO can be considered as a surgical differentiable urgency, where there aren't any signs of intestinal strangulation or peritonitis, and where the principal etiologic factor is represented by colorectal operations in the male and gynecologic operations in the female. Morbility and mortality in the surgical procedures for SBAO show greater percentages than the elderly patients.     

Randomized controlled trial of Gastrografin in adhesive small bowel obstruction

BACKGROUND: Several previous studies have shown that Gastrografin can be utilized to triage patients with adhesive small bowel obstruction (ASBO) to an operative or a non-operative course. Previous studies assessing the therapeutic effect of Gastrografin have been confounded by post-administration radiology alerting the physician to the treatment group of the patient. Therefore the aim of the present paper was to test the hypothesis that Gastrografin hastens the non-operative resolution of (ASBO). METHODS: Patients, diagnosed with ASBO on clinical and radiological grounds, were randomized to receive Gastrografin or placebo in a double-blinded fashion. Patients did not undergo further radiological investigation. If the patient required subsequent radiological intervention or surgical intervention they were excluded from the study. End-points were passage of time to resolution of ASBO (flatus and bowel motion), length of hospital stay and complications. RESULTS: Forty-five patients with ASBO were randomized to receive either Gastrografin or placebo. Two patients were excluded due to protocol violations. Four patients in each group required surgery. Eighteen of the remaining patients received Gastrografin and 17 received placebo. Patients who received Gastrografin had complete resolution of their ASBO significantly earlier than placebo patients (12 vs 21 h, P = 0.009) and this translated into a median of a 1-day saving in time in hospital (3 vs 4 days, P = 0.03). CONCLUSIONS: Gastrografin accelerates resolution of ASBO by a specific therapeutic effect.     

Natural history of patients with adhesive small bowel obstruction

BACKGROUND: Small bowel obstruction (SBO) is a major cause of morbidity and financial expenditure. The goals of this study were to determine factors predisposing to adhesive SBO, to note the long-term prognosis and recurrence rates for operative and non-operative treatment, to elicit the complication rate of operations and to highlight factors predictive of recurrence. METHODS: The medical records of all patients admitted to one hospital between 1986 and 1996 with the diagnosis of SBO were reviewed retrospectively. This included 410 patients accounting for 675 admissions. RESULTS: The frequency of previous operation by procedure type was colorectal surgery (24 per cent), followed by gynaecological surgery (22 per cent), herniorrhaphy (15 per cent) and appendicectomy (14 per cent). A history of colorectal surgery (odds 2.7) and vertical incisions (odds 2.5) tended to predispose to multiple matted adhesions rather than an obstructive band. At initial admission 36 per cent of patients were treated by means of operation. As the number of admissions increased, the recurrence rate increased while the time interval between admissions decreased. Patients with an adhesive band had a 25 per cent readmission rate, compared with a 49 per cent rate for patients with matted adhesions (P<0.004). At the initial admission 36 per cent of patients were treated surgically. Patients treated without operation had a 34 per cent readmission rate, compared with 32 per cent for those treated surgically (P not significant), a shorter time to readmission (median 0.7 versus 2.0 years; P<0.05), no difference in reoperation rate (14 versus 11 per cent; P not significant) and fewer inpatient days over all admissions (4 versus 12 days; P<0.0001). CONCLUSION: The likelihood of reobstruction increases and the time to reobstruction decreases with increasing number of previous episodes of obstruction. Patients with matted adhesions have a greater recurrence rate than those with band adhesions. Non-operative treatment for adhesions in stable patients results in a shorter hospital stay and similar recurrence and reoperation rates, but a reduced interval to reobstruction when compared with operative treatment.