Adhesive Obstruction Research Articles

Nonsurgical management of partial adhesive small-bowel obstruction with oral therapy: a randomized controlled trial

Patients with partial adhesive small-bowel obstruction are usually managed conservatively, receiving intravenous hydration and nothing by mouth. Previous studies have suggested that this approach is associated with longer hospital stays and an increased risk of delayed surgery. We conducted a randomized controlled trial to see if combining standard conservative treatment with oral administration of a laxative, a digestant and a defoaming agent would reduce the frequency of subsequent surgical intervention and reduce the length of hospital stay. We identified 144 consecutive patients admitted between February 2000 and July 2001 with adhesive partial small-bowel obstruction and randomly assigned 128 who met the inclusion criteria to either the control group (intravenous hydration, nasogastric-tube decompression and nothing by mouth) or the intervention group (intravenous hydration, nasogastric-tube decompression and oral therapy with magnesium oxide, Lactobacillus acidophilus and simethicone). The primary outcome measures were the number of patients whose obstruction was successfully treated without surgery and the length of hospital stay. We also monitored rates of complications and recurring obstructions. Of the 128 patients, 63 were in the control group and 65 in the intervention group; the mean ages were 54.4 (standard deviation [SD] 15.9) years and 53.9 (SD 16.3) years respectively. Most of the patients were male. More patients in the intervention group than in the control group had successful treatment without surgery (59 [91%] v. 48 [76%], p = 0.03; relative risk 1.19, 95% confidence interval 1.03-1.40). The mean hospital stay was significantly longer among patients in the control group than among those in the intervention group (4.2 [SD 2.7] v. 1.0 [SD 0.7] days, p < 0.001). The complication and recurrence rates did not differ significantly between the 2 groups. Oral therapy with magnesium oxide, L. acidophilus and simethicone was effective in hastening the resolution of conservatively treated partial adhesive small-bowel obstruction and shortening the hospital stay.

Prospective study on the management of patients with complicated diverticular disease

Diverticular disease is a common condition with high morbidity and mortality related to its complications. The aim of this study was to assess the predictive role of acute diverticulitis in the development of further complications from diverticular disease. Prospective assessment of all patients with complicated diverticular disease over a 1-year period in a large teaching hospital was undertaken. All patients had documented evidence of their diagnosis by radiological, endoscopic or histopathological techniques when feasible. Seventy-seven patients with complicated diverticular disease were identified. There were 53 females and 24 males with a median age of 74 years (range 30-97 years). Complications included: acute diverticulitis (37), fistula (12), perforation (8), bleeding (7), abscess (7) and stricture (6). Only 8 had two or more previous documented episodes of diverticulitis. Twenty-five underwent surgery, 3 died (peritonitis 2, abscess1) and 5 had a complication (anastomotic dehiscence 1, adhesive obstruction 1, incisional hernia 2 and pneumonia 1). Three (5%) of 37 patients with acute diverticulitis had two or more admissions but none underwent surgery or developed further complications. CT was performed during acute admission in 14/37 patients with acute diverticulitis. The majority of patients with fistula (9/12), perforation 7/8, bleeding 6/7 and abscess 5/7 had no previous episode of diverticulitis while most patients with stricture (4/6) had previous documented episodes. In our patient population acute diverticulitis is not a good predictor of the development of further complications from diverticular disease as only a minority of patients with perforation, fistula, abscess and bleeding had previous documented episodes of diverticulitis.

The Herbal Medicine, Dai-Kenchu-To, Accelerates Delayed Gastrointestinal Transit after the Operation in Rats

Post-operative ileus (POI) is a transient bowel dysmotility after operation. We have previously shown that laparotomy alone significantly delayed gastrointestinal (GI) transit, compared to anesthesia alone. The GI transit was further delayed after laparotomy plus intestinal manipulation. Dai-Kenchu-to (DKT), an herbal medicine, has been used for treating adhesive bowel obstruction in Japan. We studied whether DKT improves delayed GI transit after the operation, with or without morphine administration in rats. Under isoflurane anesthesia, POI was induced by laparotomy with intestinal manipulation. Immediately after the operation, the rats received 51Cr by gavage. Three hours after the operation, the rats were sacrificed and GI transit was estimated by calculating the geometric center (GC). DKT (120, 360, and 1,200 mg/kg) were administered by gavage after the operation, with or without morphine administration (1 mg/kg s.c.). A muscarinic receptor antagonist (atropine; 50 mug/kg), a 5HT3 receptor antagonist (ondansetron; 1 mg/kg) and a 5HT4 receptor antagonist (GR113,808; 3 mg/kg) were administered before the operation. Truncal vagotomy was performed preceding the operation. Laparotomy with intestinal manipulation produced a significant delay in GI transit (GC = 2.93 +/- 0.16), compared to that of anesthesia alone (9.51 +/- 0.45). DKT at the dose of 360 mg/kg (GC = 3.77 +/- 0.10, P < 0.01) and 1,200 mg/kg (GC = 3.77 +/- 0.20, P < 0.01) significantly accelerated delayed GI transit induced by operation. Ondansetron, GR113,808, atropine, and truncal vagotomy abolished the stimulatory effect of DKT (360 mg/kg). When morphine was administered, GI transit was further reduced (GC = 1.97 +/- 0.10). DKT at the dose of 360 mg/kg (GC = 2.81 +/- 0.22, P < 0.05) and 1,200 mg/kg (GC = 2.87 +/- 0.23, P < 0.05) significantly improved delayed GI transit in morphine treated rats. DKT accelerates delayed GI transit induced by intestinal manipulation with and without concomitant morphine administration. DKT treatment may be useful for the patients with POI.

Laparoscopy for abdominal emergencies

Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Postoperative Short Bowel Syndrome

Unanticipated massive resection after intraabdominal procedures is an increasing cause of short bowel syndrome (SBS). Our aim was to determine the frequency and potential mechanisms of postoperative SBS. We reviewed retrospectively the clinical course of 210 adult patients with SBS evaluated over a 20-year period. Fifty-two (25%) patients had postoperative SBS. The initial operations included colectomy (n=20), hysterectomy (n=8), appendectomy (n=5), gastric bypass (n=5), and other (n=14). Intestinal obstruction (n=38) was the most common reason for resection leading to SBS, either from adhesions (n=26) or volvulus (n=12). Postoperative intestinal ischemia led to resection in 14 patients. SBS occurred from 1 day postoperatively to years later, with 16 (30%) intestinal resections occurring within 1 month. Patients undergoing resection for intestinal ischemia were more likely to undergo resection during the first month than were patients with adhesions and volvulus (86% versus 4% and 25%,respectively, p < 0.05): Patients undergoing resection for ischemia and volvulus were more likely to have remnant length<60 cm compared with those with adhesions (57% and 58% versus 23%, respectively, p < 0.05). Patients undergoing resection for adhesive obstruction were more likely to undergo multiple resections. Thirty-five (67%) patients required longterm parenteral nutrition. Seven (13%) patients died, three in the early postoperative period and four from complications of SBS. SBS is a potential postoperative complication of intraabdominal procedures and accounts for a considerable proportion of tertiary referrals for SBS. Surgical treatment of postoperative obstruction after common surgical procedures is the most frequent cause. Preventing adhesions, avoiding technical errors, diagnosing a potentially ischemic intestine in a timely manner, and approaching the frozen abdomen cautiously are important strategies for preventing this condition.

Predictors of operative morbidity and mortality in gastric cancer surgery

The aim of this study was to identify factors that predict morbidity and mortality in gastric cancer surgery. Data on 719 consecutive patients who underwent operations for gastric cancer at Seoul National University Hospital between January and December 2002 were reviewed. Overall morbidity and mortality rates were 17.4 per cent (125 patients) and 0.6 per cent (four patients) respectively, and the rates of surgical and non-surgical complications were 14.7 per cent (106 patients) and 3.3 per cent (24 patients). Morbidity rates were higher in patients aged over 50 years (odds ratio (OR) 1.04 (95 per cent confidence interval (c.i.) 1.02 to 1.06)), when the gastric tumour was resected with another organ (36 per cent for combined resection versus 15.4 per cent for gastrectomy only; OR 3.25 (95 per cent c.i. 1.76 to 6.03)) and when gastrojejunostomy was used for reconstruction after subtotal gastrectomy (17.0 per cent for Billroth II versus 9.5 per cent for Billroth I; OR 2.00 (95 per cent c.i. 1.05 to 3.79)). Only three patients (2.8 per cent) with a surgical complication underwent reoperation, two for adhesive obstruction and one for intra-abdominal bleeding. Age, combined resection and Billroth II reconstruction after radical subtotal gastrectomy were independently associated with the development of complications after gastric cancer surgery.

Value of gastrografin in adhesive small bowel obstruction after unsuccessful conservative treatment: A prospective evaluation

Gastrografin is a hyperosmolar water-soluble contrast medium. Besides its predictive value for the need for operative treatment, a potential therapeutic role of this agent in adhesive small bowel obstruction has been suggested. This study aimed at evaluating the effectiveness of gastrografin in adhesive small bowel obstruction when conservative treatment failed. Patients with adhesive small bowel obstruction were given trial conservative treatment unless there was fear of bowel strangulation. Those responded in the initial 48 h had conservative treatment continued. Patients who showed no improvement in the initial 48 h were given 100 mL of gastrografin through nasogastric tube followed by serial abdominal radiographs. Patients with the contrast appeared in large bowel within 24 h were regarded as having partial obstruction and conservative treatment was continued. Patients in which the contrast failed to reach large bowel within 24 h were considered to have complete obstruction and laparotomy was performed. Two hundred and twelve patients with 245 episodes of adhesive obstruction were included. Fifteen patients were operated on soon after admission due to fear of strangulation. One hundred and eighty-six episodes of obstruction showed improvement in the initial 48 h and conservative treatment was continued. Two patients had subsequent operations because of persistent obstruction. Forty-four episodes of obstruction showed no improvement within 48 h and gastrografin was administered. Seven patients underwent complete obstruction surgery. Partial obstruction was demonstrated in 37 other cases, obstruction resolved subsequently in all of them except one patient who required laparotomy because of persistent obstruction. The overall operative rate in this study was 10%. There was no complication that could be attributed to the use of gastrografin. The use of gastrografin in adhesive small bowel obstruction after unsuccessful conservative treatment is safe and reduces the need for surgical intervention.

Abdomen agudo en el adulto mayor

Nearly 10% of emergency consultations are due to acute abdominal pain. In people over 65 years old, it can have atypical presentations, that retard the correct diagnosis and worsens prognosis. To study the causes, evolution and prognosis of acute abdomen in the elderly. Prospective study of 45 patients aged more than 65 years old (mean age+/-SD, 75.7+/-7.7, 51% men) and 221 patients of less than 65 years old (mean age+/-SD, 36.7+/-14.0, 48% men), consulting for acute abdomen in the emergency room. Sixty six percent of elderly patients had concomitant diseases, that were multiple in 63%. In this age group, the causes accounting for 71% of acute abdominal pain were bilio-pancreatic diseases (31.1%), intestinal adhesive obstruction (17.7%), complicated abdominal wall hernia (13.7%), and complications of peptic ulcer disease (8.9%). Sixty four percent required surgical treatment and, in almost 50% the surgical risk was classified in ASA III or IV, according to the American Society of Anesthesiology. Thirty one percent had postoperative complications. Compared with their younger counterparts, elderly patients required significantly (p<0.05) more admissions to intensive care units (2.7 and 24.2% respectively), more connections to mechanical ventilation (1.4 and 8.9% respectively) and longer hospital stays (5.4+/-7.4 and 12.4+/-10.9 days, respectively). In this series overall mortality was 6.7%, being 0.6% for young patients and 11.1% for the surgical group over 65 years old. Acute abdomen in the elderly has a high rate of complications and mortality. According to the causes of acute abdomen in this group, evaluation in the emergency setting with an ultrasonography may be very useful. In the elderly, elective correction of potential causes of acute abdomen should be done.

Total laparoscopic hysterectomy for oncological indications with outcomes stratified by age

Objective.We hypothesize that there is no difference in surgical outcomes of patients undergoing total laparoscopic hysterectomy (TLH) for various oncological indications when stratified by age categories. Methods.Data were analyzed by ANOVA and chi-square test with significance of P < 0.05, stratified by age (young: <50 years, middle: 50–64, senior age 65+). Results.There were 208 patients, age 26–86 years: 85 young, 82 middle, and 41 senior women. Preoperative diagnoses included 13 cases of cervical dysplasia, 10 cervical or upper vaginal carcinoma, 60 endometrial neoplasias, 22 prophylaxes of familial ovarian carcinoma, 95 with complex pelvic mass, and 8 with early ovarian carcinoma. Mean body mass index (BMI) was 27.2 kg/m2 for all groups. Parity increased with age (1.0, 1.3, and 2.0; P = 0.001). Surgical duration was longer for young than middle or senior (168, 147, and 140 min, P = 0.0095). All groups had a similar mean blood loss (133 cc, ns) and similar mean length of hospital stay (1.8 days, ns). Overall complication rate was 7.7% with no variance by age: one seroma, one hematoma, one diverticulitis, one incisional hernia, one vaginal nonhealing, one adhesive bowel obstruction, and five urologic complications (two bladder, three ureteral; four treated with catheter or stent, one reimplant. Reoperation was required in 2.8%. Conclusions.Null hypothesis accepted: TLH appears feasible and safe for oncological practice indications throughout the life span. This pilot data can facilitate guidelines for a randomized controlled trial of TLH with TAH and laparoscopic assisted vaginal hysterectomy (LAVH).

Results of a mechanical duhamel pull-through for the treatment of Hirschsprung’s disease and intestinal neuronal dysplasia

Background/purpose The authors analyzed the results of a modified entirely mechanical Duhamel pull-through for the treatment of Hirschsprung’ disease or type B intestinal neuronal dysplasia. The aim of the follow-up was to evaluate results of a Duhamel procedure entirely performed with the use of staplers. Methods Fifty-six patients were followed up to detect complications and outcome. Patients were evaluated clinically, and, when symptoms were present, a suction biopsy with histochemical analysis, an x-ray contrast enema, or an endoscopy was performed. Results Early complications developed in 4 cases (7%) including a case of leakage (1.8%). No patient experienced recurrence. During a mean follow-up of 49 months, further complications occurred in 16 other patients: 4 adhesive obstructions requiring surgery, 3 strictures, 5 chronic bleeding, 4 fecaloma formation, 2 urinary problems, and 13 postoperative enterocolitis. Four patients (7%) had more than 3 passages of liquid stools per day, and 3 of them who had an ileal pull-through had constant soiling. Thirty-seven children (68.5%) had 1 to 2 bowel movements per day and were continent. Seven (13%) had less than 3 bowel movements per week. Three children who underwent total colectomy were incontinent (5.5%). Three more children (5.5%) have not yet reached the age for continence. Forty-nine parents (87%) judged the outcome satisfactory. Conclusions Follow-up of mechanical Duhamel pull-through showed an acceptable long-term outcome. An increased risk of incontinence is present in case of ileal pull-through, whereas constipation is more frequent after partial colon resection, regardless of the type of intestinal neuronal malformation.

CONTINENT CUTANEOUS ILEAL POUCH USING THE SEROUS LINED EXTRAMURAL VALVES. THE MANSOURA EXPERIENCE IN MORE THAN 100 PATIENTS

We report on the functional results of continent ileal reservoir using serous lined extramural valves for reflux prevention and continent urinary outlet. The procedure was performed in 109 patients (68 men, 27 women and 14 children). The operation was indicated as a primary procedure in 93 patients and for conversion in 16. The technique entailed construction of a detubularized W-shaped ileal reservoir in which 2 serous lined troughs were created. Two tapered ileal segments were used, 1 for reflux prevention and the other as a continent outlet. The appendix was used for the construction of the outlet in 44 patients. Two patients died in the hospital of pulmonary embolism. A total of 22 early complications were observed in 18 patients (16.5%). None of the patients required operative intervention. A total of 93 patients were evaluable with a mean followup of 36.6 +/- 25.4 months. All evaluable patients but 5 were continent day and night. Mean time for catheterization was 4 to 5 hours. There were 14 late complications reported in 11 patients (11.8%), including pouch stones in 5, stomal stenosis in 5, failure to catheterize in 2, parastomal hernia in 1 and adhesive bowel obstruction in 1. Upper urinary tract was stable or improved in 94.8% of the renal units. Clinical acidosis did not develop in any of the patients. Serous lined unidirectional valves are reliable. They provide a versatile surgical technique suitable for urinary diversion or conversion procedures. The operation is associated with an acceptable complication rate and is followed by good functional results.

Adhesion intestinal obstruction in children in northern Nigeria.

In developing countries, reports on adhesion intestinal obstruction in children are scanty. We report 30 children managed for adhesion intestinal obstruction during a 16-year period. The age range was 10 weeks-14 years (median 9 years). There were 24 boys and 6 girls. Postoperative adhesion was the cause in 13 (43%) patients, inflammatory in 11 (37%), and in 5 (17%) no cause could be identified. In one patient, adhesion followed missed ileal perforation from blunt abdominal trauma. Duration of symptoms was 1-21 days (median 4 days). Only four of the 13 patients with postoperative adhesion obstruction were managed conservatively initially, but this failed in all; one was found to have an intestinal perforation at laparotomy. The remaining nine had immediate laparotomy owing to presence of features of strangulation at presentation; two required intestinal resection for gangrene. All other patients had laparotomy soon after resuscitation. The resection rate for gangrene was 13% and 3% required closure of perforations. Postoperatively six (20%) patients developed eight infective complications. There was recurrence in three of 27 (11%) surviving patients within 3 months. Mortality was three (10%). The presentation of adhesion intestinal obstruction in children in northern Nigeria is late and morbidity and mortality are high. Early presentation should improve the outcome.

Small bowel obstruction secondary to Crohn disease: CT findings.

We investigated the computed tomographic (CT) findings in patients with small bowel obstruction (SBO) and Crohn disease (CD). Fourteen patients, seven men and seven women (mean age, 41.3 years), were retrospectively reviewed. All presented with clinical symptoms and signs of SBO. Eleven had a history of CD, whereas three experienced the bowel obstruction as the first manifestation of the disease. On CT, features of complete SBO were seen in nine patients, whereas incomplete obstruction was found in the other five. One patient had CT findings of an adhesive obstruction. The other 13 were diagnosed as having CD-related SBO; a markedly stenotic bowel segment caused the obstruction in one patient, and a thickened-wall small bowel segment with luminal narrowing was evident at the transition zone in the other 12. The mural thickening had a target appearance in seven and homogeneous thickening in the other five. Additional thickened bowel segments were found in five patients and mesenteric involvement was found in 10. Five patients were treated conservatively, and the other nine underwent surgery (one with adhesiolysis only). Resection of the stenotic bowel was performed in six patients and stricturoplasty was done in the other two, with associated intestinal biopsy in one of these two patients. Histopathology revealed findings of active on chronic disease in all. CT is frequently performed for suspected SBO, so radiologists should be aware of the diagnosis of CD, because SBO may be its first manifestation. Alternatively, radiologists can accurately diagnose a CD-related obstruction in a patient with known CD and differentiate it from an obstruction due to adhesions. Patient management in these cases, however, is based most often on the clinical condition.

The epidemiology and treatment patterns of postoperative adhesion induced intestinal obstruction in Varsinais-Suomi Hospital District.

The epidemiology and treatment patterns of postoperative adhesion induced intestinal obstruction have been poorly investigated in Finland. This study evaluated the epidemiology and treatment patterns of postoperative adhesion induced intestinal obstruction in a well defined geographical area (Hospital District). All inpatient episodes between 1.1.1999 and 31.12.1999 due to postoperative adhesion induced intestinal obstruction in Varsinais-Suomi Hospital District were evaluated retrospectively using individual patient records. 123 hospitalizations due to postoperative adhesion-related intestinal obstruction were observed during the study period. The total number of preceding operations was 176 considering altogether 101 patients. The most prevalent single initial operations causing adhesion induced intestinal obstruction were colorectal, upper abdominal, and female reproductive system procedures. Of all treatment episodes 32% were operative and mortality was 2%. The median days of hospital stay (range) of all inpatient episodes, operative episodes, and conservative episodes were 6 (1-58), 11 (2-34) and 4 (1-58), respectively. Patient dependent factors associated with increased likelihood to operative treatment of obstruction were: female gender (40% in females vs 23% in males, P = 0.042) and previous gynaecological surgery (70% of the patients, P = 0.032). Intraoperative findings were obstruction in 70%, strangulation in 20%, necrosis in 8%, and perforation in 2% of operations. Bowel resection was needed in 38% of operations. Preceding gynaecological surgery increased the likelihood of bowel strangulation as an intraoperative finding. The epidemiology, treatment patterns and results of postoperative adhesion induced intestinal obstruction are of the average international level in the Varsinais-Suomi Hospital District. The treatment patterns among the different hospitals in the Hospital District are similar. Female gender is associated with increased risk for operative treatment of adhesive obstruction. Previous gynaecological surgery increases the likelihood of operative treatment and complicated obstruction.

Transanal one-stage endorectal pull-through for hirschsprung’s disease: a multicenter study

Background/purpose Transanal endorectal pull-through (TEPT) is the latest development in treatment of Hirschsprung’s disease (HD). This prospective study was designed to evaluate the safety and efficacy of 1 stage TEPT technique in the management of patients with HD. Methods One hundred forty-nine children (116 boys and 33 girls) aged 8 days to 14 years underwent 1 stage TEPT procedure over an 18-month period at 5 Egyptian academic pediatric surgical centers and affiliated hospitals. Median follow-up was 12 months (range, 3 to 21 months). These patients were evaluated with regard to age, sex, length of the aganglionic segment, intraoperative details, and postoperative functional results or complications. An electromyogram (EMG), endorectal ultrasound scan, and lower gastrointestinal (GI) motility studies were reserved for patients with postoperative problems with bowel control. Results Mean operating time was 120.2 ± 27.8 minutes (range, 60 to 210 minutes). The average length of resected bowel was 26.8 ± 12.4 cm (range, 15 to 45 cm). Thirteen patients required laparotomy because of extension of aganglionic segment beyond the sigmoid colon in 9, tear in the mesenteric vessels in 2, and difficulties in getting to the submucosal plane in 2. Three deaths (2%) occurred 3 days, 4 days, and 4 weeks postoperatively, respectively. Postoperative complications included transient perianal excoriation in 48 patients (30 were <3 months of age), enterocolitis (n = 26), anastomotic stricture (n = 7), recurrent constipation (n = 6), hypoganglionosis at distal end of pulled through segment (n = 2), cuff abscess (n = 3), anastomotic leak (n = 1), adhesive bowel obstruction (n = 1), and rectal prolapse (n = 1). Complete anorectal continence was noted in 35 of 42 (83.3%) children older than 3 years, whereas soiling and frequent accidents still occur in 7, who showed a steady improvement in their continence status. Conclusions One-stage TEPT technique is both feasible and safe technique in properly selected children with rectosigmoid HD in all ages. The technique is easily learned and is associated with excellent clinical results.

Outcome and complications after resection of hepatoblastoma

Purpose The aim of this study was to review the outcome and complications after resection of hepatoblastoma treated over 2 decades in our institution. Methods Clinical, radiologic, and pathologic data were reviewed retrospectively, focusing on the outcome and complications. Results Between January 1978 and December 2002, 56 children were treated for hepatoblastoma. The age range was 0.08 to 8.74 years (median, 1 year). The right lobe was involved in 48%, the left lobe in 22%, and in 29% the main bulk of the tumour was centrally located. Surgical procedures included the following: hemihepatectomy in 62%, trisegmentectomy in 18%, extended hemihepatectomy in 16%, and liver transplantation and laparotomy in one patient each. Intraoperative complications occurred in 5(9%)—rupture of the tumour (1), haemorrhage from the contralateral lobe (1), a defect in the left hepatic duct (1), cardiac arrest from tumour embolus (1), and bleeding from the inferior vena cava (1). The mean blood loss was 280 mL (50 to 2,000 mL). Postoperative complications occurred in 12 patients (22%) including subphrenic abscess (3), adhesion obstruction (2), ischaemic stenosis of the bile duct (1), abdominal wound dehiscence (1), pyloric obstruction (1), and pleural effusion (2). Fifteen patients died, 14 as a result of tumour recurrence (mortality rate, 27%).

Duodenum- and spleen-preserving total pancreatectomy for end-stage chronic pancreatitis.

Total pancreatectomy may be warranted in patients with advanced chronic pancreatitis in whom partial resection has failed and in those with end-stage pancreatic function. A new operation, duodenum- and spleen-preserving total pancreatectomy, is described. Nineteen consecutive patients with chronic pancreatitis who had duodenum- and spleen-preserving total pancreatectomy were studied. There were 15 men and four women with a median age of 40 (range 29-64) years. The aetiology was alcohol misuse in nine, hereditary pancreatitis in five and idiopathic in five patients. All patients had chronic intractable abdominal pain. Six had undergone pancreatic surgery previously and one had had multiple coeliac plexus blocks. There were ten postoperative complications in five patients, and one hospital death. The median hospital stay was 25 (range 10-84) days. There was a reduction in pain (P < 0.001) and analgesic use (P < 0.001) after surgery, and weight gain was noted at 12 and 24 months (P < 0.001). Nine patients required readmission to hospital, four because of surgical complications: adhesional obstruction in one, biliary stricture in two and duodenal obstruction in one. In the other five patients (four of whom had long-standing pre-existing diabetes mellitus) readmission was for better control of pain (three patients), diabetes mellitus (two), and diabetes-associated diarrhoea (two) or gastropathy (one). Duodenum- and spleen-preserving total pancreatectomy has a role in selected patients with medically intractable pain from chronic pancreatitis.

Delay in operative treatment among patients with small bowel obstruction.

Delay in operative treatment for small bowel obstruction (SBO) has been shown to affect outcome adversely. The objective of this study was to detect time trends in treatment delay for patients with SBO during the study period 1961 to 1995 and to investigate factors influencing and factors affected by delay. The records of 815 patients with 921 operations for SBO from 1961-1995 were studied. Patients with large bowel obstruction, paralytic ileus and SBO caused by abdominal cancer or intussusception were excluded. Data were analysed with descriptive statistics and multiple linear regression analyses. Old age and female sex were associated with increased treatment delay. Delay in hospital increased from 5 hours (median) in the 1960'ies to 16 hours (median) in the 1990'ies. Treatment delay correlated significantly with postoperative morbidity and hospital stay. Mortality increased after prolonged treatment delay in SBO caused by hernias whereas no significant increase in mortality was observed among adhesive obstructions. Hospital delay increased throughout the study period. Old patients and women had a longer median treatment delay than did young ones and men. Treatment delay led to an increase in postoperative morbidity and hospital stay after surgery for SBO.

Small bowel obstruction after total or subtotal colectomy: a 10-year retrospective review.

The aim of this retrospective study was to determine the cumulative incidence of adhesive small bowel obstruction (SBO) after total or subtotal colectomy and to investigate the site of the obstructive adhesions in the abdominal cavity. The records of 234 patients who underwent colectomy from 1985 to 1994 were reviewed for SBO, potential risk factors for SBO, and the site of adhesions causing obstruction. Mean follow-up, which was complete in 215 patients, was 63 months. SBO occurred in 56 patients (24 per cent) of whom 42 (18 per cent) had adhesive obstruction. The risk of SBO due to adhesions within 1 year was 11 per cent, increasing to 30 per cent 10 years after colectomy. With univariate analysis no risk factor for adhesive SBO, including previous laparotomies, septic complications and omental resection, was identified. The most common site of obstructing adhesions was the pelvis (ten of 28 patients). The incidence of SBO after colectomy is high. Colectomy may be a suitable model for studies of adhesion prevention.

Natural history of adhesional small bowel obstruction: counting the cost.

The aim of this study was to identify patients admitted with adhesional obstruction to determine if there was an identifiable pattern to the type of initial operation, the type of treatment used for the obstructive episode and the subsequent need for further treatment. Patients with adhesional obstruction were identified retrospectively in a cross-sectional study using ICD codes relating to admissions in the years 1990 to 1996. The case notes were used to assess their outcome. Fifty-nine case notes from a total of 175 identified initially satisfied the inclusion criteria. These patients had a mean age at presentation of 51 (range 16-88) years and had undergone a total of 122 operations. Thirty-one patients (53 per cent) had a single previous operation with a median time to presentation with obstruction of 5.5 years (range 11 days to 34.7 years); 33 patients (56 per cent) were treated conservatively on their first admission. There was no statistically significant difference in the outcome in patients who received either conservative or surgical treatment. The length of stay in patients treated surgically (median 11 (range 2-47) days) was significantly longer than that for those treated conservatively (median 6 (range 1-39) days) (P< 0.001). A flow chart was constructed demonstrating the eventual outcome of the patients in the study, enabling the cost of adhesional obstruction to be calculated. This type of approach could be used to assess the potential effect of different treatment strategies for adhesional obstruction.