Has the Use of Anti-Adhesion Barriers Affected the National Rate of Bowel Obstruction?
Department of Colorectal Surgery, Lahey Clinic, Burlington, Massachusetts, USA. The American surgeon
(Impact Factor: 0.82).
In this study, we analyzed temporal trends in anti-adhesion barrier application and admission rates for small bowel obstruction. We used data from the Nationwide Inpatient Sample and identified patients with ICD-9 codes for "application or administration of anti-adhesion barrier substances" from October 2002 through December 2007. Next, we identified cases of bowel obstruction coded from January 1997 through December 2007. We then used Kendall correlation analyses and the Joinpoint regression program to evaluate changes in trends. From October 1, 2002 through December 31, 2007, a total of 28,014 patients had an anti-adhesion barrier substance applied. During the study period, application of anti-adhesion barriers increased from 0.7 applications per 100,000 to 2.6 applications per 100,000 population (Joinpoint and Kendall; P < 0.002). Since 1997 there has been a steady rise in hospitalizations for bowel obstruction, increasing from 18.3 cases per 100,000 to 19.8 cases per 100,000 population (Joinpoint and Kendall; P < 0.002). In conclusion, the application of anti-adhesion barriers has increased significantly since 2002, yet bowel obstructions continue to be a major health problem.
Available from: Edwin K Jackson
- "Although the etiology is complex, a unifying concept proposes that surgically induced trauma and microvascular ischemia evoke a robust inflammatory response leading to activation of the coagulation system with subsequent development of fibrin deposits [3–5]. Although there are numerous therapies, including solid and fluid/gel barriers, no FDA-approved device or pharmacologic agent appears to decrease the clinical consequences of adhesions [2, 6, 7]. Clearly, novel treatments for the prevention of post-surgical adhesions and tissue protection are needed, particularly those that can be easily and conveniently administered as a solution during minimally invasive surgery and are able to protect tissues both at the surgical site and throughout the abdominal cavity. "
[Show abstract] [Hide abstract]
ABSTRACT: Intraperitoneal adenosine reduces abdominal adhesions. However, because of the ultra-short half-life and low solubility of adenosine, optimal efficacy requires multiple dosing.
Here, we compared the ability of potential adenosine prodrugs to inhibit post-surgical abdominal adhesions after a single intraperitoneal dose.
Abdominal adhesions were induced in mice using an electric toothbrush to damage the cecum. Also, 20 μL of 95 % ethanol was applied to the cecum to cause chemically induced injury. After injury, mice received intraperitoneally either saline (n = 18) or near-solubility limit of adenosine (23 mmol/L; n = 12); 5'-adenosine monophosphate (75 mmol/L; n = 11); 3'-adenosine monophosphate (75 mmol/L; n = 12); 2'-adenosine monophosphate (75 mmol/L; n = 12); 3',5'-cyclic adenosine monophosphate (75 mmol/L; n = 19); or 2',3'-cyclic adenosine monophosphate (75 mmol/L; n = 20). After 2 weeks, adhesion formation was scored by an observer blinded to the treatments. In a second study, intraperitoneal adenosine levels were measured using tandem mass spectrometry for 3 h after instillation of 2',3'-cyclic adenosine monophosphate (75 mmol/L) into the abdomen.
The order of efficacy for attenuating adhesion formation was: 2',3'-cyclic adenosine monophosphate > 3',5'-cyclic adenosine monophosphate ≈ adenosine > 5'-adenosine monophosphate ≈ 3'-adenosine monophosphate ≈ 2'-adenosine monophosphate. The groups were compared using a one-factor analysis of variance, and the overall p value for differences between groups was p < 0.000001. Intraperitoneal administration of 2',3'-cAMP yielded pharmacologically relevant levels of adenosine in the abdominal cavity for >3 h.
Administration of 2',3'-cyclic adenosine monophosphate into the surgical field is a unique, convenient and effective method of preventing post-surgical adhesions by acting as an adenosine prodrug.
[Show abstract] [Hide abstract]
ABSTRACT: Adhesions are common after intra-abdominal surgery and are associated with significant morbidity, including bowel obstruction, pain, and infertility. Abdominal wall reconstruction carries the risk of adhesion formation, notably to synthetic or bioprosthetic mesh. This article reviews the pathophysiology of adhesion formation, adhesion grading, and adhesions to synthetic and biologic mesh in vitro and clinically. Bioprosthetic mesh in vitro appears to elicit fewer lower-grade adhesions than synthetic mesh. However, direct comparisons in humans of adhesions with synthetic versus bioprosthetic mesh are lacking. Future studies are warranted to determine whether there are significant differences in clinical outcomes, especially regarding secondary complications from adhesions.
Available from: Frederick Millham
[Show abstract] [Hide abstract]
ABSTRACT: Best practices promulgated by the Eastern Association for the Surgery of Trauma suggest that delay in surgery for adhesive small bowel obstruction (ASBO) should not exceed 5 days. This study aimed to probe the relationship between operative delay and adverse outcomes, defined as occurrence of a complication, requirement for bowel resection, prolonged postoperative stay, or death in ASBO using the Nationwide Inpatient Sample.
We used the Nationwide Inpatient Sample for 2009. The relationship among days to surgery (preoperative days) and defined as occurrence of a defined set of complications, death during hospitalization, resection, and postoperative length of stay greater than 7 days (postoperative days > 7) was assessed, taking into account potential confounding factors using regression analysis.
A total of 27,046 patients were identified with small bowel obstruction; 4,826 (18%) of these required surgery, and the remainder did not, staying a mean of 4 days (median, 3 days). Of the surgical group, 1,208 patients (25.0%) had Rsx, 1,527 (32%) had postoperative days of greater than 7, 138 (2.86%) died, 3,216 (66.7%) were female. Mean age was 62.2 years, mean total length of stay was 8.51 days, mean preoperative days was 1.94 days. Odds ratio (OR) of death for operated patients was 1.64 (95% confidence interval [CI], 1.11-2.19) when preoperative days was 4 or more. Postoperative days of greater than 7 was more likely if surgery preoperative days were 4 or more (OR, 1.26; 95% CIs, 1.07-1.48). No relationship between complication and preoperative days was observed.
Delay in management of small bowel obstruction is associated with death and longer postoperative stays. Delay was not associated with complication or bowel resection. These data lend support to a policy encouraging observation of ASBO for no more than 5 days.
Epidemiologic study, level III; therapeutic study, level IV.
Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.