'Let's Just Wait One More Day': Impact of Timing on Surgical Outcome in the Treatment of Adhesion-Related Small Bowel Obstruction
Department of Surgery, University of Missouri, Columbia, Missouri, USA. The American surgeon
(Impact Factor: 0.82).
Controversy exists but most surgeons agree that surgical treatment for failed conservative management of adhesion-related small bowel obstruction (SBO) should be within 48 hours. However, many find themselves delaying definitive treatment in the hopes of resolution. Our aim was to determine what impact timing has on surgical outcomes of SBO. A retrospective review of all consecutive patients surgically treated for adhesion-related SBO was performed from January 2001 to August 2006. Study groups included patients treated emergently (less than 6 hours), expeditiously (6 to 48 hours), and delayed (greater than 48 hours). Laparoscopic, open, and converted treatment types were controlled for as confounding variables using analysis of variance. Outcome measures were return of bowel function after surgery (RBF), length of stay after surgery (LOS), and morbidity. There were 27 emergencies, 30 treated expeditiously, and 34 delayed. Groups were matched in age and gender. RBF after surgery was significantly longer for those delayed in treatment compared with those treated expeditiously (greater than 48 hours = 7.4 days vs less than 6 hours = 7.6 and 6 to 48 hours = 5.4; P < .05) as well as LOS after surgery (greater than 48 hours = 12.3 days vs less than 6 hours = 10.1 and 6 to 48 hours = 7.6; P < 0.05). Patients treated with laparoscopy within 6 to 48 hours had a significantly shorter RBF and LOS than any other combination of timing and treatment. Postoperative morbidity was higher in the delayed group (79%) than the other groups (44% emergent and 40% expeditious) (P < 0.05). There was one death in the delayed group. Delaying surgical treatment beyond 48 hours for SBO is common and results in worse outcomes and longer LOS. Laparoscopic treatment within 48 hours is superior to open treatment.
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ABSTRACT: The purpose of this study is to analyze the early experience of the laparoscopic adhesiolysis for the intestinal obstruction due to postoperative adhesion. Seven patients were included in this study. The median age of those patients was 13, and there were 3 males and 4 females. Previous diagnosis and surgical procedure were various in seven cases, including small bowel resection with tapering enteroplasty, Boix-Ochoa fundopl ication, Ladd's procedure with appendectomy, mesenteric tumor resection with small bowel anastomosis, ileocecal resection and anastomosis, primary gastric repair, and both high ligation. A successful laparoscopic adhesiolysis was performed in one who had high ligation for inguinal hernia and had a single band adhesion. Six out of 7 (86%) cases needed to convert open surgery due to multiple and dense type of adhesion. In conclusion, laparoscopic approach with postoperative small bowel adhesion seems safe. However, it might be prudently considered because of high rates of conversion in children.
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ABSTRACT: To evaluate the effect of surgical delay on the outcomes of patients with adhesive small bowel obstruction (ASBO).
It is generally accepted that patients with uncomplicated ASBO failing nonoperative management should be operated on within 5 days. However, the optimal time of operation within this 5-day period is unknown.
Patients requiring surgery for ASBO were identified from the National Surgical Quality Improvement Program database. Linear regression was performed to evaluate the impact of incremental surgical delay in mortality and complications. The study population was stratified by time to intervention (24-hour intervals), and logistic regression was performed to adjust for premorbid conditions and presentation physiology. The outcomes included 30-day mortality and infectious complications.
A total of 4163 patients underwent laparotomy for ASBO. Mortality and complications increased significantly with operative delay. Delay of 24 hours or more was associated with significantly higher mortality: 6.5% vs 3.0%; adjusted odds ratio (AOR) [95% confidence interval (CI), 1.58 (1.12-2.24)]; P = 0.009. The delayed operation group (≥24 hours) also had significantly higher rates of surgical site infections [12.9% vs 10.0%; AOR (95% CI), 1.33 (1.08-1.62); P = 0.007], pneumonia (7.9% vs 5.2%; AOR (95% CI), 1.36 (1.04-1.78); P = 0.025], sepsis [7.6% vs 5.1%; AOR (95% CI), 1.45 (1.10-1.90); P = 0.007], and septic shock [6.2% vs 3.5%; AOR (95% CI), 1.47 (1.07-2.02); P = 0.018]. Early operation was associated with significantly shorter hospital stay [8.4 ± 8.3 vs 14.4±13.5 days; adjusted mean difference (95% CI), -5.2 (-5.9 to -4.4); P<0.001].
Early operative intervention for patients with ASBO is associated with a significant survival benefit, lower incidence of local and systemic complications, and shorter hospitalization.
Available from: Stephen W Davies
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ABSTRACT: Laparotomy has been the favored approach regarding surgical management of small bowel obstruction (SBO); however, laparoscopy may offer improved outcomes. Patients undergoing laparoscopic lysis of adhesions (LOA) at our institution for SBO will have lower postoperative morbidity and 30-day mortality. Patients undergoing LOA at our institution, from 2000 to 2011, were reviewed. Categorical data were analyzed with χ(2) or Fisher's exact tests. Continuous data were analyzed with Student's t test or Wilcoxon rank sum. One hundred two (38 laparoscopic, 64 open) LOA cases were selected. Perioperative contamination and conservative management were higher in the open group. Open cases had a greater incidence of intensive care unit (ICU) admissions and longer length of stay. Stratified analysis determined a strong association between perioperative contamination and a higher incidence of ICU admission, perioperative contamination and longer LOS, and conservative management and longer LOS. Finally, patient outcome did not differ between those treated by surgeons trained in minimally invasive surgery (MIS) compared with those not trained in MIS. Careful consideration of surgical approach and timing is called for in all patients with SBO; however, whenever possible, laparoscopic preference should be given to most patients in an expeditious fashion irrespective of MIS training.
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