Results of a laparoscopic approach for the treatment of acute small bowel obstruction due to adhesions and internal hernias

Individualization of the best approach for adhesive small bowel obstruction

BACKGROUND

Laparoscopic postoperatives outcomes in adhesiolysis are promising but conversion and morbidity remains high. The objective of our study was to determine preoperative factors to individualize and select the most appropriate approach for each patient.

METHODS

Patients ≥18 years old undergoing emergent surgery for adhesive small bowel obstruction and internal hernias were evaluated. Bivariate and multivariate analysis were performed to investigate factors related to conversion to open surgery and to the type of adhesions.

RESULTS

Of 333 patients, 224 were operated by laparotomy and 109 by laparoscopy (conversion rate: 40%). Previous abdominal wall mesh, type of adhesions, bowel lesion, need for intestinal resection and laparoscopic skills were statistically related to conversion. In the multivariate analysis, complex adhesions (OR 4.3, 95% CI 1.5-12.2; P = 0.006), the need for intestinal resection (OR 14.16, 95% CI 2.55-78.68; P = 0.002), and non-advanced laparoscopy surgeons (OR 4.31, 95% CI 1.56-11.94; P = 0.005) were independent factors for conversion to open surgery. ASA III-IV, previous surgeries, previous abdominal mesh and previous adhesiolysis were related to complex adhesions. Previous laparoscopic surgery and internal hernia or closed loop in computed tomography were associated with simple adhesions as a cause of the obstruction. In the multivariate, previous adhesiolysis (OR 4.76, 95% CI 1.23-18.3; P = 0.023) and the findings on computed tomography were significantly related with the type of adhesion.

CONCLUSION

Some preoperative factors allow to individualize the surgical approach in the adhesive small bowel obstruction improving surgical outcomes.

Age, blood urea nitrogen, and lactate: Preoperative risk factors of laparotomy for strangulated small bowel obstruction

INTRODUCTION

Despite increasing reports of laparoscopy for strangulated small bowel obstruction (SSBO), there is no consensus on outcomes in patients with SSBO. We evaluated the safety and utility of laparoscopy for SSBO and investigated the preoperative risk factors for laparotomy.

METHODS

This retrospective study included 107 patients who underwent emergency surgery for SSBO over a period of 6 years. Patients' characteristics and surgical parameters were compared between 27 patients undergoing laparoscopy alone (group L) and 80 patients undergoing laparotomy (group O, including conversion). Univariate and multivariate analyses were performed to determine risk factors for laparotomy.

RESULTS

Compared with group L, group O had significantly shorter operation time (59 vs 115 minutes, P < .001), shorter postoperative hospital stay (6 vs 10 days, P < .001), and fewer complications (3 vs 40 cases, P < .001). Age ≥ 68 years (odds ratio [OR] 3.970, P = .021), blood urea nitrogen (BUN) ≥ 14.6 mg/dL (OR 4.360, P = .012), and lactate ≥2.80 mmol/L (OR 12.90, P = .023) were independent risk factors for laparotomy.

CONCLUSION

Prognosis was better in patients with SSBO undergoing complete laparoscopy than in patients undergoing laparotomy; however, age, BUN, and lactate were independent preoperative risk factors for laparotomy.

The role of the laparoscopic approach in the surgical management of acute adhesive small bowel obstruction

Background

Postoperative adhesions represent 75% of all acute small bowel obstructions. Although open surgery is considered the standard approach for adhesiolysis, laparoscopic approach is gaining popularity.

Methods

A retrospective study with data from a prospectively maintained data base of all patients undergoing surgical treatment for adhesive small bowel obstruction (ASBO) from January 2007 to May 2016 was conducted. Postoperative outcomes comparing open vs laparoscopic approaches were analysed. An intention to treat analysis was performed. The aim of the study was to evaluate the potential benefits of the laparoscopic approach in the treatment of ASBO.

Results

262 patients undergoing surgery for ASBO were included. 184 (70%) and 78 (30%) patients were operated by open and laparoscopic approach respectively. The conversion rate was 38.5%. Patients in the laparoscopic group were younger (p < 0.001), had fewer previous abdominal operations (p = 0.001), lower ASA grade (p < 0.001), and less complex adhesions were found (p = 0.001). Operative time was longer in the open group (p = 0.004). Laparoscopic adhesiolysis was associated with a lower overall complication rate (43% vs 67.9%, p < 0.001), lower mortality (p = 0.026), earlier oral intake (p < 0.001) and shorter hospital stay (p < 0.001). Specific analysis of patients with single band and/or internal hernia who did not need bowel resection, also demonstrated fewer complications, earlier oral intake and shorter length of stay. In the multivariate analysis, the open approach was an independent risk factor for overall complications compared to the laparoscopic approach (Odds Ratio = 2.89; 95% CI 1.1–7.6; p = 0.033).

Conclusions

Laparoscopic management of ASBO is feasible, effective and safe. The laparoscopic approach improves postoperative outcomes and functional recovery, and should be considered in patients in whom simple band adhesions are suspected. Patient selection is the strongest key factor for having success.

Relaparoscopy for management of postoperative complications following colorectal surgery: ten years experience in a single center

BACKGROUND

Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant disease. On the basis of this growing experience, there is now an expanded role for laparoscopic approach to postoperative complications after primary colorectal resection. However, there is little literature specific to this topic. We report a ten-year experience with laparoscopic treatment of early complications following laparoscopic colorectal surgery.

METHODS

From January 2003 to December 2012, a total of 1,292 patients underwent elective laparoscopic colorectal surgery in our department. One hundred and two (7.9%) patients required reoperation for a postoperative complication. Laparoscopy has been also adopted as the preferred procedure for management of postoperative complications. A retrospective review of 84 patients who had relaparoscopy (RL) for postoperative complications, including peritonitis, ureteral injury, bowel obstruction, and bleeding, was performed.

RESULTS

Reoperation was carried out laparoscopically in 79 (94.0%) patients. Five (6.0%) conversions were necessary because of massive colonic ischemia, generalized fecal peritonitis, and lack of working space. The most common finding at RL was anastomotic leakage (57.1%) that was managed by peritoneal lavage and ileostomy in 91.7% of cases. Six percent of patients had negative RL. Overall morbidity rate was 25.0%. Five patients required additional surgery: four (5.1%) after RL and one after a converted procedure. There were five (6.0%) deaths from septic shock, myocardial infarction, and pulmonary embolism.

CONCLUSIONS

Laparoscopy is a safe and effective tool for management of complications following laparoscopic colorectal surgery. In this setting, RL represents the first step of re-exploration and treatment, with no delay to conversion to open procedure even in skilled laparoscopic hands.