Adhesiolysis For Small Bowel Obstruction Research Articles

Characterization of peritoneal reactive ascites collected from acute appendicitis and small bowel obstruction patients

BackgroundPathological abdominal adhesions can cause bowel obstructions. A history of appendectomy (appy) increases patient rehospitalization risk directly related to adhesions. To potentially identify strategies for adhesion treatment, we characterized reactive ascites (rA) collected during appy or adhesiolysis for small bowel obstruction (SBO). MethodsThis is a non-randomized, prospective observational study recruiting patients with non-perforated appendicitis or SBO from three Level 1 trauma centers in the United States. rA were analyzed via liquid chromatography-mass spectrometry (LC-MS) (n = 31), bead-based quantification cytokines and chemokines (n = 32) and soluble receptors (n = 30), and LC-MS metabolomics (n = 18). ResultsLC-MS showed that samples contained albumin, apolipoprotein A1, and transthyretin and that metabolites increased in SBO vs appy rA were biomarkers of oxidative stress. Multi-plex analyses showed levels of 17 cytokines/chemokines and 6 soluble receptors were significantly different in appy vs SBO rA. Top increased proteins in appy compared to SBO rA by 20.14-, 11.53-, and 8.18-fold were granulocyte-colony stimulating factor, C-X-C motif chemokine ligand 10, and interleukin-10, respectively. ConclusionsThese data further define pro- and anti-inflammatory mediators and metabolites that may drive formation or perpetuate chronic abdominal adhesions. Future research is to further explore whether attenuation of these factors may decrease pathologic adhesion formation.

Revised cardiac risk index poorly predicts cardiovascular complications after adhesiolysis for small bowel obstruction

BackgroundThe number of patients undergoing preoperative risk stratification in the United States is expected to increase as the population ages. A large percentage of patients undergo some form of preoperative testing, and society guidelines suggest that up to 50% of the testing in lower risk surgical subgroups is unnecessary. The Revised Cardiac Risk Index and the risk calculator of the American College of Surgeons National Surgical Quality Improvement Program are widely used tools as the first step of preoperative cardiac evaluation. The Revised Cardiac Risk Index was developed to fill a need for objective perioperative cardiac risk evaluation. Despite the ease of use of Revised Cardiac Risk Index, it is uncertain if the stratification is accurate for surgical patients because its accuracy in large surgical samples has not been tested. With the National Surgical Quality Improvement Program risk calculator having excellent accuracy in estimating cardiac complications (area under the receiver operating characteristic 0.895), a unique opportunity to test the predictive accuracy of postsurgical cardiac events became available. The purpose of this study is to determine the accuracy of the Revised Cardiac Risk Index for predicting cardiovascular complications after adhesiolysis for small bowel obstruction. MethodsFrom 2005 to 2015, 34,032 cases of open or laparoscopic adhesiolysis (Current Procedural Terminology codes 44005 and 44180) for small bowel obstruction (International Classification of Diseases, 10th edition [ICD-10]) were analyzed using the National Surgical Quality Improvement Program dataset. Revised Cardiac Risk Index estimates were calculated for each case and compared to reported cardiovascular complications (myocardial infarction or cardiac arrest) using univariable logistic regression. Overall predictive accuracy was assessed by measuring model discrimination (area under the receiver operating characteristic) and model calibration (Hosmer-Lemeshow chi-squared statistics). ResultsAlthough the Revised Cardiac Risk Index predicted cardiovascular complications with an odds ratio of 2.3 and a 95% confidence interval of 1.9 to 2.8 (P < .001) and the Hosmer-Lemeshow chi-square was significant (0.22, P = 0.64), the area under the receiver operating characteristic was poor (0.63, 95% confidence interval 0.59–0.67). ConclusionDespite its relative simplicity, the Revised Cardiac Risk Index performed poorly as a predictor of cardiovascular complications after adhesiolysis for small bowel obstruction. These findings question the utility of the Revised Cardiac Risk Index in this patient population. Future studies should aim to develop models that are computationally simple while retaining predictive accuracy.

A simple predictor of post-operative complications after open surgical adhesiolysis for small bowel obstruction

BackgroundSmall bowel obstruction is common and often requires surgical management. Simple preoperative models are lacking to predict post-operative complications after surgical management of adhesive small bowel obstruction. MethodsWe retrospectively analyzed data from 15,036 patients who underwent open lysis of adhesions for small bowel obstruction from 2005 to 2013 using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Predictors of post-operative complications were identified using logistic regression. Predictive models were compared using areas under the receiver operating characteristic curves (AUROC). ResultsA three-parameter model was constructed, termed FAS: Functional status, American Society of Anesthesiologists (ASA) classification, and prior Sepsis. FAS predicted post-operative complications with odds ratio (OR) 1.11, 95% CI (1.10, 1.12), P < 0.001 and AUROC of 0.69, 95% CI (0.67, 0.70). ConclusionsFAS predicts post-operative complications after open lysis of adhesions using three readily available clinical parameters.

Early laparoscopic adhesiolysis for small bowel obstruction: retrospective study of main advantages.

The problem of managing adhesional small bowel obstruction (ASBO) is still unsolved. A conservative medical attitude is privileged even if it is associated to a high rate of recurrences, while surgery is applied to cases showing no improvement after 48-72h. Adhesiolysis via laparotomy has been the standard surgical management, but it causes other adhesions in a vicious circle. The aim of the study is to evaluate the advantages of early laparoscopic adhesiolysis as an alternative approach. From January 2010 to April 2017, 107 patients were admitted with a diagnosis of ASBO. Patients underwent medical treatment, early surgery, emergency surgery or delayed surgery after failure of medical treatment. A retrospective review and explorative statistical analysis were performed using graphical diagnostic plots, Mann-Whitney (MW) test, Kolmogorov-Smirnov (KS) test, exact binomial test, and χ 2 test. Medical treatment led to resolution in the 77.3% of cases, but patients exhibit much more recurrences than those in the surgical group (χ 2 p < .001). They also show a longer fasting time (MW p = .027; KS p = .102), a doubled number of radiological exams (MW p < .001; KS p < .001), and more major complications than those in the early surgery group. Early surgery group is associated to shorter fasting time (MW p < .001; KS p < .001), much shorter hospital stay (MW p < .001; KS p = .002) and a smaller number of radiological exams (MW p = .005; KS p = .002) compared with delayed surgery group. The laparoscopic group shows significantly earlier regain of intestinal transit (MW p < .001; KS p = .002), shorter fasting time (MW p = .002; KS p = .008), reduced number of radiological exams (MW p = .003; KS p = .014), reduced hospital stay (MW p < .001; KS p = .005), and no more complications than the open surgery group. Early laparoscopic surgery can be proposed as an effective alternative treatment for ASBO.

Does laparoscopic adhesiolysis decrease the risk of recurrent symptoms in small bowel obstruction? A propensity score-matched analysis.

The outcomes of laparoscopic adhesiolysis for small bowel obstruction have generally been satisfactory over the short term. However, the long-term outcomes, including recurrence of symptoms and management of recurrence, remain controversial. This study compares the long-term outcomes of a series of laparoscopic and open surgery procedures for the treatment of small bowel obstruction. Patients who underwent adhesiolysis for small bowel obstruction at our institution between 2008 and 2015 were retrospectively reviewed. In total, 156 patients were enrolled, 78 with laparoscopic and 78 with open surgery. Propensity score matching was used to minimize the bias in patient selection. Long-term outcomes included incidence of recurrent symptoms and reoperation. In addition to the comparison of outcomes, risk factor assessment for recurrent symptoms and analysis of detailed information in patients with reoperation were performed. Statistical methods included χ 2 test, Mann-Whitney U test, Cox proportional hazards model, and Kaplan-Meier plots with log-rank comparison. Laparoscopy was performed in a younger population with milder bowel dilation and less complicated etiologies. These factors were used to construct the propensity score model, which yielded a matched cohort of 52 legs in each group. Laparoscopy achieved good short-term outcomes including early recovery of gastrointestinal function, reduced incidence of complications, and shorter hospital stay. For long-term outcomes, while the overall recurrence rate did not differ between the groups (11.5 vs 7.7%), the incidence of reoperation for recurrence was significantly higher in the laparoscopically treated group (7.7 vs 0%, p=.017). The Cox proportional hazards model showed that multiple prior surgeries (≥3 times) were a risk factor for overall recurrence (hazard ratio 7.39, p=.041). Laparoscopic adhesiolysis did not decrease the incidence of recurrent symptoms; rather, it was related to higher incidence of recurrent small bowel obstruction requiring surgical treatment.

Impact of hospital volume on outcomes for laparoscopic adhesiolysis for small bowel obstruction

BackgroundVolume-to-outcome data have been studied in several complex surgical procedures, demonstrating improved outcomes at higher volume centers. Laparoscopic lysis of adhesions (LLOA) for small bowel obstruction (SBO) may result in better outcomes, but there is no information on the learning curve for this potentially complex case. This study evaluates the effect of institutional procedural volume on length of stay (LOS), outcomes, and costs in LLOA for SBOs. Materials and methodsThe Nationwide Inpatient Sample data set between 2000 and 2013 was queried for discharges for a diagnosis of SBO involving LLOA in adult patients. Patients with intra-abdominal malignancy and evidence of any other major surgical procedure during hospitalization were excluded. The procedural volume per hospital was calculated over the period, and high-volume hospitals were designated as those performing greater than five LLOA per year. Patient characteristics were described by hospital volume status using stratified cluster sampling tabulation and linear regression methods. LOS, total charges, and costs were reported as means with standard deviation and median values. P < 0.05 was considered significant. ResultsA total of 9111 discharges were selected, which was representative of 43,567 weighted discharges nationally between 2000 and 2013. Over the study period, there has been a 450% increase in the number of LLOA performed. High-volume hospitals had significantly shorter LOS (mean: 4.92 ± standard error (SE) 0.13 d; median: 3.6) compared to low-volume hospitals (mean: 5.68 ± 0.06 d; median: 4.5). In multivariate analysis, high-volume status was associated with a decreased LOS of 0.72 d (P < 0.0001) as compared to low-volume status. Other significant predictors for decreased LOS included decreased age, decreased comorbidity, and the absence of small bowel resection. There was no significant association between volume status and total charges in multivariate or univariate models, but high-volume hospitals were associated with lower costs in multivariate models by approximately $984 (P = 0.017). ConclusionsThis study demonstrates that high hospital volume was associated with decreased LOS for LLOA in SBO. Although volume was not associated with differences in total charges, there was a small decrease in hospital costs.

Laparoscopic versus open adhesiolysis for small bowel obstruction - a multicenter, prospective, randomized, controlled trial

BackgroundLaparoscopic adhesiolysis is emerging as an alternative for open surgery in adhesive small bowel obstruction. Retrospective studies suggest that laparoscopic approach shortens hospital stay and reduces complications in these patients. However, no prospective, randomized, controlled trials comparing laparoscopy to open surgery have been published.Methods/DesignThis is a multicenter, prospective, open label, randomized, controlled trial comparing laparoscopic adhesiolysis to open surgery in patients with computed-tomography diagnosed adhesive small bowel obstruction that is not resolving with conservative management. The primary study endpoint is the length of postoperative hospital stay in days.Sample size was estimated based on preliminary retrospective cohort, which suggested that 102 patients would provide 80% power to detect a difference of 2.5 days in the length of postoperative hospital stay with significance level of 0.05. Secondary endpoints include passage of stool, commencement of enteral nutrition, 30-day mortality, complications, postoperative pain, and the length of sick leave. Tertiary endpoints consist of the rate of ventral hernia and the recurrence of small bowel obstruction during long-term follow-up. Long-term follow-up by letter or telephone interview will take place at 1, 5, and 10 years.DiscussionTo the best of our knowledge, this trial is the first one aiming to provide level Ib evidence to assess the use of laparoscopy in the treatment of adhesive small bowel obstruction.Trial registrationClinicalTrials.gov identifier: NCT01867528. Date of registration May 26th 2013.

Should adhesive small bowel obstruction be managed laparoscopically? A National Surgical Quality Improvement Program propensity score analysis

Celiotomy is the most common approach for refractory small bowel obstruction (SBO). Small reviews suggest that a laparoscopic approach is associated with shorter stay and less morbidity. Given the limitations of previous studies, we sought to evaluate outcomes of laparoscopic (L) compared with open (O) adhesiolysis for SBO, using the National Surgical Quality Improvement Program data set. Patients from the American College of Surgeons' National Surgical Quality Improvement Program 2005 to 2009 database who underwent surgery for SBO were stratified based on surgical approach. A propensity score to undergo L instead of O was calculated based on demographics, comorbidities, physiology, and laboratory values. Logistic regression was then used to determine differences in outcomes between those propensity score-matched patients who actually underwent L compared with O surgery. There were 6,762 patients who underwent adhesiolysis. The propensity score-matching process created 222 matched patients in L and O groups. Laparoscopy was associated with significantly lower rates of any complication (odds ratio [OR] 0.41; 95% confidence interval [CI], 0.28-0.60), including superficial site infections (OR, 0.15; 95% CI, 0.05-0.49), intraoperative transfusion (OR, 0.22; 95% CI, 0.05-0.90), and shorter hospital stay (4 days vs. 10 days; p < 0.001). There was no significant difference in operative time, rates of reoperation within 30 days, or mortality. Laparoscopic treatment of SBO is associated with lower rates of postoperative morbidity compared with laparotomy as well as shorter hospital stay. Laparoscopic treatment of surgical SBO is not associated with higher rates of early reoperation and seems to be associated with lower resource use. Therapeutic study, level IV.

Pilot study on laparoscopic surgery in port-harcourt, Nigeria.

Background:Video-laparoscopic surgery has long been practiced in western countries; however documented practice of this minimal access surgical technique are recently emanating from Nigeria. To the best of our knowledge, this is the first documented study on laparoscopic surgery from the Niger Delta region.Aim:To evaluate the feasibility of laparoscopy as a useful tool for management of common surgical abdominal conditions in our environment.Patients and Methods:This was a prospective outcome study of all consecutive surgical patients who had laparoscopic procedures in general and pediatric surgery units of our institution from August 2011 to December 2012. Data on patient's age, gender, indication for surgery, duration of hospital stay and outcome of surgery were collected and analyzed.Results:A total of 15 laparoscopic procedures were performed during this study period with age range of 2-65 years; mean: 32.27 ± 17.86 years. There were 11 males and four females. Six laparoscopic appendicectomies, one laparoscopy-assisted orchidopexy, five diagnostic laparoscopy ± biopsy, one laparoscopic trans-abdominal pre-peritoneal herniorrhaphy for bilateral indirect inguinal hernia and two laparoscopic adhesiolysis for small bowel obstruction were performed. All were successfully completed except one conversion (6.7%) for uncontrollable bleeding in an intra-abdominal tumor.Conclusion:The practice of laparoscopic surgery in our environment is feasible and safe despite the numerous, but surmountable challenges. There is the need for adequate training of the support staff and a dedicated theatre suite.

Feasibility of laparoscopy for small bowel obstruction.

BackgroundAdherential pathology is the most common cause of small bowel obstruction. Laparoscopy in small bowel obstruction does not have a clear role yet; surely it doesn't always represent only a therapeutic act, but it is always a diagnostic act, which doesn't interfere with abdominal wall integrity.MethodsWe performed a review without any language restrictions considering international literature indexed from 1980 to 2007 in Medline, Embase and Cochrane Library. We analyzed the reference lists of the key manuscripts. We also added a review based on international non-indexed sources.ResultsThe feasibility of diagnostic laparoscopy is high (60–100%), while that of therapeutic laparoscopy is low (40–88%). The frequency of laparotomic conversions is variable ranging from 0 to 52%, depending on patient selection and surgical skill. The first cause of laparotomic conversion is a difficult exposition and treatment of band adhesions. The incidence of laparotomic conversions is major in patients with anterior peritoneal band adhesions. Other main causes for laparotomic conversion are the presence of bowel necrosis and accidental enterotomies. The predictive factors for successful laparoscopic adhesiolysis are: number of previous laparotomies ≤ 2, non-median previous laparotomy, appendectomy as previous surgical treatment causing adherences, unique band adhesion as phatogenetic mechanism of small bowel obstruction, early laparoscopic management within 24 hours from the onset of symptoms, no signs of peritonitis on physical examination, experience of the surgeon.ConclusionLaparoscopic adhesiolysis in small bowel obstruction is feasible but can be convenient only if performed by skilled surgeons in selected patients. The laparoscopic adhesiolysis for small bowel obstruction is satisfactorily carried out when early indicated in patients with a low number of laparotomies resulting in a short hospital stay and a lower postoperative morbidity. Although a higher small bowel obstruction recurrence remains the major postoperative risk of the laparoscopic management of these patients.

Electronic Clinical Challenges and Images in GI

Electronic Clinical Challenges and Images in GI

Encapsulating peritoneal sclerosis-a life-threatening condition treated successfully with adhesiolysis and Jones tube insertion.

Sir, Encapsulating sclerosing peritonitis, a life-threatening abdominal disease, is characterized by the formation of multiple fibrous adhesions. This leads to a ‘cocoon’ of fibrous tissue, encapsulating either the small or whole bowel— causing intestinal obstruction. It was first recognized as a complication of peritoneal dialysis (PD) in 1980 [1], where it usually presents as small bowel obstruction, ascites or ultrafiltration failure. It is thought to be related to both duration of catheter use and peritoneal membrane transport characteristics, being more common in ‘fast transporters’ [2]. Convincing evidence of cure has come only from adhesiolysis, which releases the fibrous adhesions [1]. Intraluminal stenting after adhesiolysis for small bowel obstruction was first described by White in 1956. Despite the technique being modified by Munro and Jones in 1978 [3], it has never gained widespread popularity in the UK. The major complication of surgery is a high recurrence rate. In one series, 11/47 patients (23.4%) experienced recurrence, 10 undergoing a second operation, and 4 requiring a third operation [4]. The mortality is uncertain, with a wide range reported (2–56%). The rationale for our technique was to further reduce mortality and recurrence rate, and provide an alternative to drug treatments (e.g. immunosuppression) whose side effects carry considerable morbidity. A 69-year-old woman, on PD for 10 years for ERF, was converted to haemodialysis in January 2003 due to recurrent peritonitis. In June 2003, she presented with recurrent ascites. An abdominal CT scan (below) suggested multiple encapsulating loculated collections in the abdomen. TPN was given for 6 weeks before surgical intervention. In September 2003, a laparotomy revealed encysted dense adhesions and a large pseudocyst in the pelvis entrapping the bowel. The adhesions were released and a Jones tube was placed through the entire length of the gastrointestinal tract. A Jones tube is a 3 m (18 gauge) tube with side perforations and a balloon at the distal end. During surgery, the tube was advanced via the nasogastric route through the entire length of the bowel and the distal end came out of the rectum. The balloon was inflated and the small bowel arranged in orderly fashion, so that even if fibrosis did occur, the bowel did not get entrapped. This was left in situ for 1 week, with TPN and haemodialysis continuing. She was discharged 7 months later and is currently well on haemodialysis, with no evidence of recurrence. In ERF patients, encapsulating peritoneal sclerosis is a rare disease and is usually a long-term complication of peritoneal dialysis. This type of surgery has to be slow (4 h in our case) and careful, releasing bowel from fibrous bands all along its length. Adhesiolysis with intraluminal stenting should be considered as an option in the treatment of encapsulating peritoneal sclerosis. Conflict of interest statement. None declared.

Laparoscopic adhesiolysis for small bowel obstruction

Background Historically, laparotomy and open adhesiolysis have been the treatment for patients requiring surgery for small bowel obstruction. Laparoscopic adhesiolysis has not gained wide acceptance. The indications and outcomes of laparoscopic adhesiolysis for small bowel obstruction are not well established. The purpose of this paper is to review the literature on laparoscopic adhesiolysis for small bowel obstruction and to discuss patient selection, surgical technique, and outcomes. Data sources Medline search from 1980 to 2002. Conclusions Laparoscopic adhesiolysis has been shown to be safe and feasible in experienced hands. For selected patients, laparoscopic adhesiolysis offers the advantages of decreased length of stay, faster return to full activity, and decreased morbidity. Patient selection and surgical judgment appear to be the most important factors for a successful outcome.

Laparoscopic Lysis of Adhesions

The surgical treatment of small bowel obstruction is evolving. Laparoscopic exploration and adhesiolysis is increasingly being utilized. We conducted a retrospective chart review of all patients who were operated on and discharged with the diagnosis of adhesiolysis for small bowel obstruction (SBO) from July 1999 to October 2000 at Cedars-Sinai Medical Center. There were a total of 75 patients. Patients were grouped based on the type of operation: laparoscopic (lap), open, and converted. Thirty-four patients were attempted laparoscopically, 11 of those requiring conversion to open. Fifty-two patients were treated with a laparotomy. Complications contributing to morbidity were significantly lower in the lap group (P < 0.01). There was no difference in morbidity between the converted and open groups. There were fewer pneumonias and wound infections in the lap group when compared to the open group, although it did not reach statistical difference. The reduction of post-op ileus in the lap group was statistically significant (P < 0.01). Statistically significant differences between the lap and open groups were also found in estimated blood loss (EBL) (P < 0.004), length of stay (LOS) (P < 0.01), bowel resection (P < 0.01) and op-time (P < 0.003). Laparoscopic release of adhesions is a viable option in the surgical management of small bowel obstruction. A prospective randomized trial comparing both surgical techniques is needed to further validate the laparoscopic approach to small bowel obstruction.