Small Bowel Obstruction Following Restorative Proctocolectomy: Affected by a Laparoscopic Approach?

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53792-7375, USA.
Journal of Surgical Research (Impact Factor: 1.94). 03/2011; 170(2):202-8. DOI: 10.1016/j.jss.2011.03.004
Source: PubMed


Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the gold standard surgical treatment for chronic ulcerative colitis. More recently, this procedure is being performed laparoscopically assisted. Postoperatively, small bowel obstruction (SBO) is one of the more common associated complications. However, it is unknown whether the addition of a laparoscopic approach has changed this risk. This study aims to assess and compare the incidence of SBOs after both open and laparoscopic restorative proctocolectomy.
All subjects who underwent restorative proctocolectomy from 1998-2008 were identified from a prospective Colorectal Surgery Database. Medical records were reviewed for all cases of SBO, confirmed by a combination of clinical symptoms and radiologic evidence. Comparisons were made between laparoscopic and open approaches. The incidence of SBO was also subdivided into pre-ileostomy takedown, early post-ileostomy takedown (30 d post), and late post-ileostomy takedown (30 d to 1 y post). Several potential risk factors were also evaluated. Statistical analysis was performed utilizing Fisher's exact (for incidence) or t-tests (for means). Significance was defined as P < 0.05
A total of 290 open cases and 100 laparoscopic cases were identified during this time period. The overall incidence of SBO at 1 y post-ileostomy takedown was 14% (n = 42) in the open group and 16% (n = 16) laparoscopic (P = NS). In the pre-ileostomy takedown period the incidence of SBO was 7% (n = 21) open and 13% (n = 13) laparoscopic (P = NS). While in the post-takedown period, the early incidence was 4% (n = 12) open and 1% (n = 1) laparoscopic and late incidence was 3% (n = 9) open and 2% (n = 2) laparoscopic (P = NS). Factors associated with an increased risk of SBO include coronary artery disease, prior appendectomy and W and J pouch configurations.
The burden of postoperative small bowel obstruction after restorative proctocolectomy is not changed with a laparoscopic approach. Most cases occur in the early postoperative period, especially prior to ileostomy reversal.

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Available from: Gregory Kennedy, Jul 09, 2015
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    • "Some studies report a dramatic reduction in post-operative intestinal obstruction for certain procedures such as cholecystectomy and gynecological pelvic procedures [2]. However, Scholin did not find a reduced rate of post-operative intestinal obstruction after laparoscopic colon and rectal surgical procedures [24] [25]. There were limitations that we encountered while conducting this study. "
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    • "In our own series, the rate of SBO occurence was 23% in patients who underwent open TPC and IPAA. Some papers have debated the rate of bowel obstruction between the two different approaches for this operation [15] [16] [17]. Our data indicate that surgical approach was the only significant independent multivariable predictor of SBO and that incidence of SBO is higher and occurs earlier in the open group. "
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    ABSTRACT: Laparoscopic techniques have been applied to restorative proctocolectomy since the early 2000's. We have employed a technique for laparoscopic-assisted total proctocolectomy (TPC) and ileal pouch anal anastomosis (IPAA) for the treatment of children with ulcerative colitis (UC). We retrospectively reviewed 68 laparoscopic-assisted TPCs and 39 open TPCs performed at our institution for UC between January 1997 and February 2011. Case duration, postoperative length of stay, and complications of the two groups were compared, and multivariable analysis was applied. The two groups were comparable with respect to gender, age, and postoperative length of stay. Total abdominal colectomy (TAC) duration was significantly longer in the laparoscopic-assisted group (P < .001). Complications were similar in the laparoscopic and open group, although small bowel obstruction (SBO) was significantly less frequent in the laparoscopic group (log-rank test = 8.88, P = .003). Kaplan-Meier estimated freedom from SBO at 1 year follow-up is 99% for patients treated laparoscopically (95% CI: 98%-100%) and 76% for those undergoing an open surgical approach (95% CI: 64%-88%). The significantly lower SBO rate, low complication rates, and equivalent length of stay favor use of the laparoscopic-assisted approach for TPC and IPAA in children.
    Journal of Pediatric Surgery 07/2013; 48(7):1546-50. DOI:10.1016/j.jpedsurg.2012.08.031 · 1.39 Impact Factor
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    • "However, it seems likely that the higher rate of EPSBO in cases with a history of laparotomy is related to the severity of adhesion, which is in-line with previous suggestions that postoperative adhesion was increased more in the patients with a previous history of laparotomy [7, 25, 26]. However, one report suggested that previous abdominal surgery does not increase the incidence of small bowel obstruction in patients with ulcerative colitis [27]. "
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    ABSTRACT: Postoperative small bowel obstruction is a common and serious complication following a proctectomy, and early postoperative small bowel obstruction (EPSBO) leads to longer hospital stays, delays chemotherapy in advanced cases, and may be a contributor to mortality. The goal of this study is to identify the risk factors of EPSBO after a proctectomy for rectal cancer, thereby seeking to reduce the incidence of EPSBO. Patients (735) who underwent a proctectomy for rectal cancer between March 2005 and February 2010 were entered into this study, and data were collected prospectively. Patients were judged to have EPSBO if, within the first 30 days, they presented symptoms such as nausea, vomiting and abdominal distention lasting for 2 days, and radiologic finding of small bowel obstruction after evidence of return of small bowel motility. The association between EPSBO and patients and surgery-related variables were studied by using univariate and multivariate analyses. EPSBO developed in 47 cases (6.4%) and was the most frequently occurring complication in the early perioperative period following a proctectomy. The frequency of EPSBO according to operative variables shows that EPSBO developed in 3.0% of the patients who underwent laparoscopic surgery (LS) compared with 8.4% of the patients who underwent open surgery (OS) (P = 0.004). OS (odds ratio [OR], 2.5) and a previous laparotomy (OR, 2.3) were independent risk factors for the development of EPSBO after a proctectomy for rectal cancer. EPSBO is more likely to occur in patients who undergo OS or who have had a previous laparotomy. LS may be considered as a surgical procedure that can reduce the risk of EPSBO in patients undergoing a proctectomy for rectal cancer.
    Journal of the Korean Society of Coloproctology 12/2011; 27(6):315-21. DOI:10.3393/jksc.2011.27.6.315
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