Adhesional small bowel obstruction after colorectal surgery

BACKGROUND: Acute clinical indicators of complications in colorectal surgery can be readily attained but it is much harder to gather indicators of long-term outcomes such as small bowel obstruction (SBO). However, with improved in-hospital data collection and coding such information is becoming available. The aim of the present study was to examine our own hospital database for SBO rates post-colorectal surgery. METHODS: The database was searched and then the relevant medical records were reviewed of all patients admitted to Flinders Medical Centre (Bedford Park, Australia) between July 1999 and November 2002 with a diagnosis of SBO following a colorectal procedure during this same time period. RESULTS: There were 21 patients that accounted for 28 readmissions from a total colorectal procedure group of 583 patients. The arbitrary subgroups were: 13/325 (4%) for colonic resections; 7/186 (3.7%) for rectal resections; 0/12 (0%) for laparotomies/other procedures; and 1/39 (2.6%) for stoma formation/reversals. The overall SBO rate requiring readmission was therefore 3.6%/pt in the 3 years. There was a large variation in the first readmission interval, 38% occurred within 3 months, 43% between 3 and 12 months, and 19% after 1 year. At the first readmission 38% of patients had operative treatment. The mean length of stay was 6.12 days for non-operative vs 21.62 days for operative treatment. CONCLUSION: The reported rate of SBO of 3.6% (at 3 years time interval) is in accordance with other studies. With 38% of patients being treated operatively at first admission there is good acceptance for conservative management in non-strangulated SBO. The prolonged hospital stay for patients needing surgery warrants further investigation.     

Long-term prognosis after operation for adhesive small bowel obstruction

AIM OF STUDY: The objective of this study was to determine the pattern of recurrence after one or more episodes of adhesive small bowel obstruction (ASBO) during a follow-up period of up to 40 years. Furthermore, we wanted to analyze possible factors with an influence on the recurrence rate and to study the magnitude of "everyday" abdominal pain among these patients. PATIENTS AND METHODS: Hospital records of 500 patients operated on for adhesive obstruction at Haukeland University Hospital from 1961 to 1995 were studied. The patients were followed until death, loss to follow-up, or end of study (February 2002), with a median follow-up of 10 years and a maximum follow-up time of 40 years. A questionnaire was sent to all living patients to obtain information on recurrences and abdominal complaints. RESULTS: The cumulative recurrence rate for patients operated once for ASBO was 18% after 10 years and 29% at 30 years. For patients admitted several times for ASBO, the relative risk of recurrent ASBO increased with increasing number of prior ASBO episodes. The cumulative recurrence rate reached 81% for patients with 4 or more ASBO admissions. Other factors influencing the recurrence rate were the method of treatment of the last previous ASBO episode (conservative versus surgical) and the number of abdominal operations prior to the initial ASBO operation. Compared to results from the general populations, more ASBO patients suffer from abdominal pain at home. Women and patients having matted adhesions have significantly more complaints about abdominal pain than men and patients with band adhesions. CONCLUSION: The risk of recurrence increased with increasing number of ASBO episodes. Most recurrent ASBO episodes occur within 5 years after the previous one, but a considerable risk is still present 10 to 20 years after an ASBO episode. Surgical treatment decreased the risk of future admissions for ASBO, but the risk of new surgically treated ASBO episodes was the same regardless of the method of treatment. People treated for ASBO seem to be more prone to experiencing abdominal pain than the normal population, especially those having matted adhesions.     

Low incidence of adhesion-related bowel obstruction after laparoscopic colorectal surgery

BACKGROUND: Postoperative adhesions are a major cause of morbidity, accounting for approximately 5% of the readmissions of surgical patients. Bowel obstruction is attributed to adhesions in more than half of the cases, many of which are following colon and rectal surgery. Laparoscopic surgery has the potential advantage of reduced adhesion formation owing to attenuated surgical trauma, less tissue handling, and smaller scars. However, the translation of these advantages to a reduced rate of bowel obstruction has not been sufficiently demonstrated. The aim of this study was to assess the rate of adhesion-related bowel obstruction after laparoscopic colon and rectal surgery. METHODS: Data regarding all cases of laparoscopic colon and rectal surgery were prospectively collected. Information relative to demographics, surgical procedures, and follow-up was analyzed, and patients who were readmitted for bowel obstruction were identified. RESULTS: Over a period of 8 years, 306 patients, at a mean age of 63 years, had a laparoscopic colon and rectal operation in our department-122 for benign conditions and 184 for malignant disease. The mean length of follow-up was 38 months. Six cases (2%) of bowel obstruction, which were unrelated to hernia or advanced cancer, were identified. Two patients had a history of open surgery, in addition to the laparoscopic procedure, so adhesions could be attributed solely to the laparoscopic procedure in 4 patients, which consisted of 1.3% of the total study group. Obstruction occurred within 2 weeks of surgery in 2 patients, and one early reoperation was required. CONCLUSIONS: The incidence of adhesion ileus after laparoscopic colon and rectal surgery appears to be very low. This long-term benefit of laparoscopic surgery should be considered when comparing this technique to its open counterpart.     

术后早期炎症性肠梗阻的治疗

目的：探讨术后早期炎症性肠梗阻的治疗。方法：回顾性分析21例术后早期炎症性肠梗阻的临床资料。结果：手术治疗10例，术后症状完全缓解6例，术后再次出现肠梗阻3例，术后并发肠瘘死亡1例。保守治疗11例均部分或完全缓解，平均治疗时间10．5d。其中2例出现慢性肠梗阻，1例出现反复发作的肠梗阻，此3例分别在术后3，4，6个月后行手术治疗。结论：术后早期炎症性肠梗阻的治疗原则应先行保守治疗。手术适应症为：（1）合并腹腔脓肿；（2）出现肠绞窄表现；（3）出现固定扩张的肠袢；（4）保守治疗治愈或缓解后出现慢性肠梗阻或反复发作的肠梗阻。前3项可早期手术，而后者以保守治疗3个月手术为宜。     

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直肠癌术后复发的治疗是一个非常棘手的问题 ,由于多种疗法介入到该领域 ,使医生及病人在选择治疗方法上意见不尽一致。近日 ,我科治疗了 2个病例。 1例是 6 5岁的女性 ,直肠癌术后 2年 ,慢性肠梗阻 ,合并双侧输尿管梗阻、无尿。术前ＣＴ检查为盆腔及后腹壁转移 ,结肠高度扩张 ,经几家医院会诊 ,认为已属晚期 ,手术意义不大。在征求病人及家属同意的条件下 ,进行开腹探查 ,将盆腔及后腹壁可见肿瘤全部切除 ,将双侧输尿管从肿瘤中分离出来 ,病人术后恢复良好 ,排便、排尿正常。另 1例是一 4 5岁女性 ,直肠癌术后 8个月复发 ,有腹膜转移结节及…     

Results of surgery for colorectal carcinoma with obstruction

Background/aims  Emergency surgery for obstructing colorectal carcinoma is thought to be associated with poor survival. The aim of the study is to assess the results of surgery for obstructing colorectal cancer. Materials and methods  From 1987 to 2004, 80 patients underwent emergency surgery for completely obstructing colorectal carcinoma (COC), and 171 patients underwent elective surgery for non-obstructing cancer (NOC). Morbidity, mortality, and the late outcome were assessed. Results  The groups were comparable for age, gender, tumor distribution, histopathologic characteristics, stage, morbidity, concomitant operations, recurrence, and sites of recurrence. High ASA class, poor performance status, and high mortality rate were recorded in COC group (p < 0.05). Mortality was related to ASA class (p < 0.001), performance status (p < 0.001), and obstruction (p = 0.014). ASA class was the single independent factor of morbidity (p < 0.001). The groups were comparable for survival (p > 0.05). Conclusions  Obstructing colorectal carcinoma seems to be associated with high mortality rate, but long-term survival seems to be the same with non-obstructing carcinoma.     

Small bowel obstruction after appendicectomy

BACKGROUND: This study analysed the risk of surgically treated small bowel obstruction after open appendicectomy. METHODS: This was a historical cohort study of 245 400 patients who underwent open appendicectomy and population-based matched controls, identified by linkage of computer registries. Analyses were made with the life-table technique, Kaplan-Meier plots and Cox proportional hazards regression analysis. RESULTS: The cumulated risk of surgically treated small bowel obstruction after appendicectomy was 0.41 per cent after 4 weeks, 0.63 per cent after 1 year and 1.30 per cent after 30 years of follow-up, compared with 0.003 per cent at 1 year and 0.21 per cent after 30 years of follow-up among the non-operated controls. The highest risk was found after operation for other diagnoses (adjusted hazard ratio 5.2 (95 per cent confidence interval 4.6-5.8)), followed by operation for perforated appendicitis (adjusted hazard ratio 3.5 (3.1-3.8)), non-specific abdominal pain (adjusted hazard ratio 2.6 (2.3-3.0)) and mesenteric lymphadenitis (adjusted hazard ratio 2.4 (2.0-2.8)) compared with operation for non-perforated appendicitis. The relation with age was J shaped, with the lowest risk at 20-39 years. Women had a slightly lower risk than men. CONCLUSION: The risk of postoperative small bowel obstruction needing surgical treatment after open appendicectomy is lower than previously thought. Perforated appendicitis, negative appendicectomy and high age are the risk factors.     

Prevalence and risk factors of mortality and morbidity after operation for adhesive postoperative small bowel obstruction

BACKGROUND: Many factors are believed to influence the mortality and morbidity after operations for adhesive small bowel obstruction (SBO). METHODS: In a multicenter prospective cohort of 286 patients operated on for adhesive postoperative SBO, we studied the in-hospital and 30-day postdischarge mortality (early mortality) and morbidity as well as long-term mortality using univariate and multivariate analysis. RESULTS: In the present cohort, with a median follow-up of 41 months and 9% patients lost to follow-up at the end of the study, the prevalence of early postoperative mortality was 3%. All deceased patients were over 75 years old with an American Society of Anesthesiologists (ASA) class >/=III. The prevalence of long-term mortality was 7% with the following independent risk factors: age >75 years old (hazards ratio [HR] 6.6 [95% confidence interval [CI], 2.4-18.1]), medical complications (HR 7.4 [CI, 2.2-24.3]), and a mixed mechanism of obstruction (HR 4.5 [CI, 1.5-13.7]). Prevalence of medical and surgical morbidity was 8% and 6%, respectively. Independent risk factors for medical complications were ASA class >/=III (odds ratio [OR] 16.8 [CI, 2.1-133.1]) and bands (OR 14.1 [CI, 1.8-111.5]) and for the surgical complications the number of obstructive structures >/=10 (OR 8.3 [CI, 1.6-19.7]), a nonresected intestinal wall injury (OR 5.3 [CI, 1.5-18.3]), and intestinal necrosis (OR 5.6 [CI, 1.6-19.7]). Otherwise, 3 patients with "apparent" reversible ischemia developed a postoperative intestinal necrosis followed by 2 reoperations and 1 death. CONCLUSION: The early postoperative mortality is strongly linked with the age and the ASA class and the long-term mortality with postoperative complications. More frequent bowel resections might be suggested for patients featuring a number of obstructive structures >/=10 and an intestinal wall injury, especially when associated with a reversible intestinal ischemia.     

结直肠癌并急性肠梗阻31例治疗分析

目的探讨结直肠癌并急性肠梗阻的外科治疗原则和方法。方法回顾性分析我院1999年1月～2009年12月收治的31例合并急性肠梗阻的结直肠癌临床资料。结果术中出现并发症8例（25.8%）,其中切口感染3例,切口裂开1例,腹腔感染1例,肺部感染2例,1例死亡,其余痊愈出院,无一例发生吻合口瘘。结论结直肠癌合并急性肠梗阻多属中晚期,手术是解除梗阻的有效方法,术式选择应根据病变部位和病情而定,做好围手术期处理是减少并发症、降低病死率的关键。     

Small bowel obstruction after FloSeal use

Objective:

FloSeal is a thrombin-gelatin hemostatic matrix that is used to obtain hemostasis. There have been isolated case reports of FloSeal causing bowel obstructions, requiring surgical intervention. We report 3 cases of what we believe were FloSeal-induced small bowel obstructions (SBO).

Methods:

We present a series of small bowel obstructions after FloSeal use. Our series includes urology, gynecologic oncology, and general surgery cases at the same institution where the product was appropriately used and resulted in the same complication.

Results:

FloSeal was used for hemostasis in all patients. In each instance, a small bowel obstruction developed in 7 days to 9 days. All patients were reexplored laparoscopically and found to have an intense inflammatory reaction at the site of the FloSeal. The adhesions were lysed and the obstructions resolved.

Conclusions:

Although further study is needed, the common factor in all these SBOs was a hemostatic agent. In our and others’ series, the time to SBO was 7 days to 9 days. If an early postoperative SBO occurs after FloSeal is used, prompt reexploration should be considered.     

Successful one-stage operation for completely obstructive colorectal carcinoma

We describe herein a new and successful method of performing a safe and steady one-stage operation for completely obstructive colorectal carcinoma. First, a long ileus tube is utilized to decompress the dilated proximal bowel preoperatively and irrigate the feces-loaded colon intraoperatively. Following this procedure, a standard resection with radical lymph node dissection is carried out without a diverting colostomy. We performed this procedure successfully in seven patients, none of whom developed any anastomotic leakage.     

Bladder outlet obstruction after operation for ureterocele.

Two patients with ureterocele-induced bladder outlet obstruction are presented. In each instance, a broad-based diverticulum had developed in the floor of the bladder as a result of the muscular defect created by a simple ureterocele in one patient and an ectopic ureterocele in the other. This bladder diverticulum produced secondary obstruction of the bladder outlet during the act of voiding. Urinary diversion in one patient had been carried out because of bladder outlet obstruction and was being seriously considered in the other patient because of upper tract deterioration. After the correct diagnosis was established, reconstruction of the muscular defect eliminated the obstruction and reestablished satisfactory bladder function. Urinary diversion was thus prevented in one patient and undiversion accomplished in another, when the true obstructing nature of the bladder diverticulum was established and correct therapy instituted.     

大肠癌致肠梗阻的外科处理(附52例报告)

目的　探讨大肠癌致肠梗阻的外科处理方法。方法　分析 1995 1999年间 5 2例大肠癌致肠梗阻的外科治疗资料。结果　 5 2例病人 ,Ⅰ期行右半结肠切除 9例 ;Ⅰ期行横结肠癌切除 4例 ;Ⅰ期行左半结肠或直肠上段癌切除 ,近端结肠造口 ,关闭远端结肠或直肠备Ⅱ期吻合 37例。肿瘤无法切除行乙状结肠造口 2例 (直肠癌 )。术后并发症发生率 15 3 % (8/5 2 ) ,围手术期病死率 3 8% (2 /5 2 )。结论　重视对结肠癌致肠梗阻的认识。合理选择手术方式 ,做好围手术期处理是减少并发症 ,提高疗效的重要措施。     

直肠癌术后早期肠梗阻的临床特点和治疗

目的 探讨直肠癌手术后早期肠梗阻的临床特点和手术时机。方法 回顾分析直肠癌手术４０８例术后早期肠梗阻２６例的临床资料。结果 ２１例经手术探查发出以机械性梗阻占多数（１９／２１），手术治愈１８例，死亡３例，死亡原因均为延误手术时机造成。非手术治愈５例。结论 直肠癌术后早期肠梗阻虽有梗阻症状，但由于术后诸多 影响，大多缺乏典型机械性梗阻的临床表现，易与术后肠麻痹，炎性粘连梗阻相混淆，应注意加以鉴别。处     

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目前，外科手术是甲状腺癌主要的治疗方法。甲状腺癌手术仍然是风险较大的手术之一。有作者提出，现代甲状腺外科手术死亡率已达到0的水平，这种过于乐观的观点对临床实际工作未必有益。其它非致死性甲状腺手术并发症仍常见报道，有的医院因连续出现甲状腺手术并发症而限制了工作的进一步正常开展，均应引起充分重视。本文讨论甲状腺癌手术后呼吸道梗阻的发生原因及其处理原则。     

Prevalence of reoperation for pathway obstruction after Fontan operation

Among 334 patients undergoing the Fontan operation at two institutions and followed for a long time, freedom from reoperation for Fontan pathway obstruction was 99% at 1 year after operation and 96%, 86%, and 59%, respectively, at 5, 10, and 15 years after operation. The hazard function for reoperation had an initial very rapidly declining phase and a second phase that was still rising 15 years after operation. Twelve (17%; confidence limits [CL], 13% to 23%) of 69 patients with a right atrial to right ventricular conduit (valved or nonvalved) connection underwent reoperation for pathway obstruction, whereas only 2 (4%; CL, 1% to 10%) of 45 patients with a direct connection to the right ventricle required reoperation. Five (8%; CL, 4% to 13%) of 65 patients with a right atrial to pulmonary artery conduit connection required reoperation for pathway obstruction, and only 2 (1.3%; CL, 0.4% to 3%) of 155 patients with a direct right atrial to pulmonary artery connection required reoperation. These findings have implications as to the optimal technique of the Fontan operation and also as to use of an intraatrial tunnel as part of the repair.