1
|
Liang JT, Liao YT, Chen TC, Huang J, Hung JS. Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer. Int J Surg 2024; 110:1577-1585. [PMID: 38051917 PMCID: PMC10942203 DOI: 10.1097/js9.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023]
Abstract
INTRODUCTION This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC). METHODS Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups. RESULTS The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n =68/1544 vs. 9.7%, n =156/1604, P <0.0001). Compared with the TOS group, the MIS group had significantly different ( P <0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to ( P <0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3-12 months) onset (64.7%), while that in the TOS group ( P <0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more ( P <0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8 vs. 14.1%, P =0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group. CONCLUSIONS The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.
Collapse
Affiliation(s)
- Jin-Tung Liang
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, Taipei
| | - Yu-Tso Liao
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu
| | - Tzu-Chun Chen
- Department of Surgical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan, Republic of China
| | - John Huang
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, Taipei
| | - Ji-Shiang Hung
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, Taipei
| |
Collapse
|
2
|
Khan WH, Abaid A, Butt UI, Warraich MU, Ayyaz M, Shafiq A. Efficacy of Cross-Linked Hyaluronic Acid Gel for the Reduction of Post-operative Obstructive Symptoms Due to Adhesions. Cureus 2022; 14:e22469. [PMID: 35371704 PMCID: PMC8942047 DOI: 10.7759/cureus.22469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/05/2022] Open
|
3
|
Zindel J, Mittner J, Bayer J, April-Monn SL, Kohler A, Nusse Y, Dosch M, Büchi I, Sanchez-Taltavull D, Dawson H, Gomez de Agüero M, Asahina K, Kubes P, Macpherson AJ, Stroka D, Candinas D. Intraperitoneal microbial contamination drives post-surgical peritoneal adhesions by mesothelial EGFR-signaling. Nat Commun 2021; 12:7316. [PMID: 34916513 PMCID: PMC8677808 DOI: 10.1038/s41467-021-27612-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/01/2021] [Indexed: 12/19/2022] Open
Abstract
Abdominal surgeries are lifesaving procedures but can be complicated by the formation of peritoneal adhesions, intra-abdominal scars that cause intestinal obstruction, pain, infertility, and significant health costs. Despite this burden, the mechanisms underlying adhesion formation remain unclear and no cure exists. Here, we show that contamination of gut microbes increases post-surgical adhesion formation. Using genetic lineage tracing we show that adhesion myofibroblasts arise from the mesothelium. This transformation is driven by epidermal growth factor receptor (EGFR) signaling. The EGFR ligands amphiregulin and heparin-binding epidermal growth factor, are sufficient to induce these changes. Correspondingly, EGFR inhibition leads to a significant reduction of adhesion formation in mice. Adhesions isolated from human patients are enriched in EGFR positive cells of mesothelial origin and human mesothelium shows an increase of mesothelial EGFR expression during bacterial peritonitis. In conclusion, bacterial contamination drives adhesion formation through mesothelial EGFR signaling. This mechanism may represent a therapeutic target for the prevention of adhesions after intra-abdominal surgery.
Collapse
Affiliation(s)
- Joel Zindel
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Department of Pharmacology and Physiology and Snyder Institute for Chronic Diseases and Department of Microbiology, Immunology & Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Jonas Mittner
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Julia Bayer
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon L April-Monn
- Clinical Pathology Division and Translational Research Unit, Institute of Pathology, University of Bern, Bern, Switzerland
| | - Andreas Kohler
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ysbrand Nusse
- Department of Pharmacology and Physiology and Snyder Institute for Chronic Diseases and Department of Microbiology, Immunology & Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michel Dosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Isabel Büchi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Sanchez-Taltavull
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heather Dawson
- Clinical Pathology Division and Translational Research Unit, Institute of Pathology, University of Bern, Bern, Switzerland
| | - Mercedes Gomez de Agüero
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kinji Asahina
- Southern California Research Center for Alcoholic Liver and Pancreatic Diseases and Cirrhosis and Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
- Central Research Laboratory, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Paul Kubes
- Department of Pharmacology and Physiology and Snyder Institute for Chronic Diseases and Department of Microbiology, Immunology & Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew J Macpherson
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Deborah Stroka
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
4
|
Pallan A, Dedelaite M, Mirajkar N, Newman PA, Plowright J, Ashraf S. Postoperative complications of colorectal cancer. Clin Radiol 2021; 76:896-907. [PMID: 34281707 DOI: 10.1016/j.crad.2021.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/09/2021] [Indexed: 12/12/2022]
Abstract
Colorectal cancer is the third most common cancer, and surgery is the most common treatment. Several surgical options are available, but each is associated with a range of potential complications. The timely and efficient identification of these complications is vital for effective clinical management of these patients in order to minimise their morbidity and mortality. This review aims to describe the range of commonly performed surgical treatments for colorectal surgery. In addition, frequent post-surgical complications are explored with investigative options explained and illustrated.
Collapse
Affiliation(s)
- A Pallan
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK.
| | - M Dedelaite
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - N Mirajkar
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - P A Newman
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - J Plowright
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - S Ashraf
- Department of Colorectal Surgery, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| |
Collapse
|
5
|
Zwicky SN, Stroka D, Zindel J. Sterile Injury Repair and Adhesion Formation at Serosal Surfaces. Front Immunol 2021; 12:684967. [PMID: 34054877 PMCID: PMC8160448 DOI: 10.3389/fimmu.2021.684967] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/23/2021] [Indexed: 12/19/2022] Open
Abstract
Most multicellular organisms have a major body cavity containing vital organs. This cavity is lined by a mucosa-like serosal surface and filled with serous fluid which suspends many immune cells. Injuries affecting the major body cavity are potentially life-threatening. Here we summarize evidence that unique damage detection and repair mechanisms have evolved to ensure immediate and swift repair of injuries at serosal surfaces. Furthermore, thousands of patients undergo surgery within the abdominal and thoracic cavities each day. While these surgeries are potentially lifesaving, some patients will suffer complications due to inappropriate scar formation when wound healing at serosal surfaces defects. These scars called adhesions cause profound challenges for health care systems and patients. Therefore, reviewing the mechanisms of wound repair at serosal surfaces is of clinical importance. Serosal surfaces will be introduced with a short embryological and microanatomical perspective followed by a discussion of the mechanisms of damage recognition and initiation of sterile inflammation at serosal surfaces. Distinct immune cells populations are free floating within the coelomic (peritoneal) cavity and contribute towards damage recognition and initiation of wound repair. We will highlight the emerging role of resident cavity GATA6+ macrophages in repairing serosal injuries and compare serosal (mesothelial) injuries with injuries to the blood vessel walls. This allows to draw some parallels such as the critical role of the mesothelium in regulating fibrin deposition and how peritoneal macrophages can aggregate in a platelet-like fashion in response to sterile injury. Then, we discuss how serosal wound healing can go wrong, causing adhesions. The current pathogenetic understanding of and potential future therapeutic avenues against adhesions are discussed.
Collapse
Affiliation(s)
- Simone N Zwicky
- Department of Visceral Surgery and Medicine, Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Deborah Stroka
- Department of Visceral Surgery and Medicine, Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Joel Zindel
- Department of Visceral Surgery and Medicine, Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| |
Collapse
|
6
|
Zindel J, Peiseler M, Hossain M, Deppermann C, Lee WY, Haenni B, Zuber B, Deniset JF, Surewaard BGJ, Candinas D, Kubes P. Primordial GATA6 macrophages function as extravascular platelets in sterile injury. Science 2021; 371:371/6533/eabe0595. [PMID: 33674464 DOI: 10.1126/science.abe0595] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 01/08/2021] [Indexed: 12/14/2022]
Abstract
Most multicellular organisms have a major body cavity that harbors immune cells. In primordial species such as purple sea urchins, these cells perform phagocytic functions but are also crucial in repairing injuries. In mammals, the peritoneal cavity contains large numbers of resident GATA6+ macrophages, which may function similarly. However, it is unclear how cavity macrophages suspended in the fluid phase (peritoneal fluid) identify and migrate toward injuries. In this study, we used intravital microscopy to show that cavity macrophages in fluid rapidly form thrombus-like structures in response to injury by means of primordial scavenger receptor cysteine-rich domains. Aggregates of cavity macrophages physically sealed injuries and promoted rapid repair of focal lesions. In iatrogenic surgical situations, these cavity macrophages formed extensive aggregates that promoted the growth of intra-abdominal scar tissue known as peritoneal adhesions.
Collapse
Affiliation(s)
- J Zindel
- Department of Pharmacology and Physiology, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Visceral Surgery and Medicine, Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - M Peiseler
- Department of Pharmacology and Physiology, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M Hossain
- Department of Pharmacology and Physiology, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - C Deppermann
- Department of Pharmacology and Physiology, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - W Y Lee
- Department of Pharmacology and Physiology, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - B Haenni
- Institute of Anatomy, University of Bern, Bern, Switzerland
| | - B Zuber
- Institute of Anatomy, University of Bern, Bern, Switzerland
| | - J F Deniset
- Department of Pharmacology and Physiology, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - B G J Surewaard
- Department of Pharmacology and Physiology, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - D Candinas
- Department of Visceral Surgery and Medicine, Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - P Kubes
- Department of Pharmacology and Physiology, University of Calgary, Calgary, Alberta, Canada. .,Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
7
|
Sakari T, Christersson M, Karlbom U. Mechanisms of adhesive small bowel obstruction and outcome of surgery; a population-based study. BMC Surg 2020; 20:62. [PMID: 32252752 PMCID: PMC7137409 DOI: 10.1186/s12893-020-00724-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/24/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND This study aims to describe the mechanisms of adhesive small bowel obstruction (SBO) and its morbidity, mortality and recurrence after surgery for SBO in a defined population. METHOD Retrospective study of 402 patients (240 women, median age 70 years, range 18-97) who underwent surgery for SBO in the Uppsala and Gävleborg regions in 2007-2012. Patients were followed to last note in medical records or death. RESULT The cause of obstruction was a fibrous band in 56% and diffuse adhesions in 44%. Early overall postoperative morbidity was 48 and 10% required a re-operation. Complications, intensive care and early mortality (n = 21, 5.2%) were related to age (p < 0.05) and American Society of Anesthesiologist's class (p < 0.01). At a median follow-up of 66 months (0-122), 72 patients (18%) had been re-admitted because of SBO; 26 of them underwent a re-operation. Previous laparotomies (p = 0.013), diffuse adhesions (p = 0.050), and difficult surgery (bowel injury, operation time and bleeding, p = 0.034-0.003) related to recurrent SBO. The cohort spent 6735 days in hospital due to SBO; 772 of these days were due to recurrent SBO. In all, 61% of the cohort was alive at last follow-up. Late mortality was related to malignancies, cardiovascular disease, and other chronic diseases. CONCLUSIONS About half of patients with SBO are elderly with co-morbidities which predispose to postoperative complications and mortality. Diffuse adhesions, which make surgery difficult, were common and related to future SBO. Overall, nearly one-fifth of patients needed re-admission for recurrent SBO. Continued research for preventing SBO is desirable. TRIAL REGISTRATION The study was registered at ClinicalTrials.gov (NCT03534596, retrospectively registered, 2018-05-24).
Collapse
Affiliation(s)
- Thorbjörn Sakari
- Department of Surgical Sciences, Uppsala University, Gävle Hospital, SE-803 24, Gävle, Sweden.
| | - Malin Christersson
- Department of Surgical Sciences, Uppsala University, University Hospital, Uppsala, Sweden
| | - Urban Karlbom
- Department of Surgical Sciences, Uppsala University, University Hospital, Uppsala, Sweden
| |
Collapse
|
8
|
Krielen P, Grutters JPC, Strik C, Ten Broek RPG, van Goor H, Stommel MWJ. Cost-effectiveness of the prevention of adhesions and adhesive small bowel obstruction after colorectal surgery with adhesion barriers: a modelling study. World J Emerg Surg 2019; 14:41. [PMID: 31428188 PMCID: PMC6698039 DOI: 10.1186/s13017-019-0261-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 08/05/2019] [Indexed: 02/07/2023] Open
Abstract
Background Adhesion barriers have proven to reduce adhesion-related complications in colorectal surgery. However, barriers are seldom applied. The aim of this study was to determine the cost-effectiveness of adhesion barriers in colorectal surgery. Methods A decision-tree model was developed to compare cost-effectiveness of no adhesion barrier with the use of an adhesion barrier in open and laparoscopic surgery. Outcomes were incidence of clinical consequences of adhesions, direct healthcare costs, and incremental cost-effectiveness ratio per adhesion prevented. Deterministic and probabilistic sensitivity analyses were performed. Results Adhesion barriers reduce adhesion incidence and incidence of adhesive small bowel obstruction in open and laparoscopic surgery. Adhesion barriers in open surgery reduce costs compared to no adhesion barrier ($4376 versus $4482). Using an adhesion barrier in laparoscopic procedures increases costs by $162 ($4482 versus $4320). The ICER in the laparoscopic cohort was $123. Probabilistic sensitivity analysis showed 66% and 41% probabilities of an adhesion barrier reducing costs for open and laparoscopic colorectal surgery, respectively. Conclusion The use of adhesion barriers in open colorectal surgery is cost-effective in preventing adhesion-related problems. In laparoscopic colorectal surgery, an adhesion barrier is effective at low costs.
Collapse
Affiliation(s)
- Pepijn Krielen
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P C Grutters
- 2Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands.,3Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chema Strik
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Richard P G Ten Broek
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harry van Goor
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martijn W J Stommel
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
9
|
Mege D, Colombo F, Stellingwerf ME, Germain A, Maggiori L, Foschi D, Buskens CJ, de Buck van Overstraeten A, Sampietro G, D'Hoore A, Bemelman W, Panis Y. Risk Factors for Small Bowel Obstruction After Laparoscopic Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease: A Multivariate Analysis in Four Expert Centres in Europe. J Crohns Colitis 2019; 13:294-301. [PMID: 30312385 DOI: 10.1093/ecco-jcc/jjy160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although laparoscopy is associated with a reduction in adhesions, no data are available about the risk factors for small bowel obstruction [SBO] after laparoscopic ileal pouch-anal anastomosis [IPAA]. Our aims here were to identify the risk factors for SBO after laparoscopic IPAA for inflammatory bowel disease [IBD]. METHODS All consecutive patients undergoing laparoscopic IPAA for IBD in four European expert centres were included and divided into Groups A [SBO during follow-up] and B [no SBO]. RESULTS From 2005 to 2015, SBO occurred in 41/521 patients [Group A; 8%]. Two-stage IPAA was more frequently complicated by SBO than 3- and modified 2-stage IPAA [12% vs 7% and 4%, p = 0.04]. After multivariate analysis, postoperative morbidity (odds ratio [OR] = 3, 95% confidence interval [CI] = 1.5-7, p = 0.002), stoma-related complications [OR = 3, 95% CI = 1-6, p = 0.03] and long-term incisional hernia [OR = 6, 95% CI = 2-18, p = 0.003] were predictive factors for SBO, while subtotal colectomy as first surgery was an independent protective factor [OR = 0.4, 95% CI = 0.2-0.8, p = 0.002]. In the subgroup of patients receiving restorative proctocolectomy as first operation, stoma-related or other surgical complications and long-term incisional hernia were predictive of SBO. In the patient subgroup of subtotal colectomy as first operation, postoperative morbidity and long-term incisional hernia were predictive of SBO, whereas ulcerative colitis and a laparoscopic approach during the second surgical stage were protective factors. CONCLUSIONS We found that SBO occurred in less than 10% of patients after laparoscopic IPAA. The study also suggested that modified 2-stage IPAA could potentially be safer than procedures with temporary ileostomy [2- and 3-stage IPAA] in terms of SBO occurrence.
Collapse
Affiliation(s)
- D Mege
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - F Colombo
- Department of Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - M E Stellingwerf
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - A Germain
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - L Maggiori
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - D Foschi
- Department of Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - C J Buskens
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | | | - G Sampietro
- Department of Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - A D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - W Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Y Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| |
Collapse
|
10
|
Sheyn D, Bretschneider CE, Mahajan ST, Ridgeway B, Davenport A, Pollard R. Incidence and risk factors of early postoperative small bowel obstruction in patients undergoing hysterectomy for benign indications. Am J Obstet Gynecol 2019; 220:251.e1-251.e9. [PMID: 30471258 DOI: 10.1016/j.ajog.2018.11.1095] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/30/2018] [Accepted: 11/15/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Small bowel obstruction (SBO) is a major cause of postoperative mortality and morbidity following abdominal and pelvic surgery, with 225,000-345,000 annual admissions. SBO may be classified based on onset from day of surgery. Early SBO occurs within the first 30 days following surgery, whereas late SBO occurs after the initial 30-day postoperative window. The majority of either type of bowel obstruction is believed to be secondary to intra-abdominal adhesions. Early SBO warrants special attention because of the difficulty in distinguishing between mechanical and nonmechanical obstruction during this period. Whereas conservative management often leads to resolution of nonmechanical obstruction and some partial SBO, surgical management is associated with a higher rate of complications compared to surgery for late SBO because of the presence of hypervascular adhesions in the early postoperative period. The current literature regarding SBO, and early SBO in particular, following hysterectomy is limited. Given that approximately 400,000 hysterectomies are performed annually, understanding the risk factors associated with SBO following these types of surgeries is imperative for improving patient outcomes. OBJECTIVE The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO) after hysterectomy for benign indications. MATERIALS AND METHODS This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Data on patient demographics and clinical and surgical factors were obtained. Patients were then stratified into those with and those without SBO. Pairwise comparison was performed using the Wilcoxon rank-sum test and Fisher exact tests. Multivariable logistic regression was used to identify significant independent predictors of SBO. RESULTS Of 47,937 hysterectomies, SBO occurred in 286 patients, at a rate of 5.9 per 1000 hysterectomies. Comparing patients with and without SBO, those with an obstruction were older (49 vs 46 years, P <.001) and were more likely to smoke (21.0% vs 15.8%, P = .02), to have a history of prior abdominal surgery (73.4% vs 65.4%, P = .005), and to have medical comorbidities such as hypertension and dyspnea. Patients experiencing SBO were also more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, P < .001), adhesiolysis (5.2% vs 2.1%, P < .001), appendectomy (1.7% vs 0.5%, P = .02), and cystotomy repair (1.0% vs 0.3%, P = .002). After logistic regression, route of hysterectomy was not a significant risk factor for SBO, whereas wound class ≥3 (adjusted odds ratio [aOR], 5.96; 95% confidence interval [CI], 2.71-12.99) and perioperative transfusion (aOR, 5.01; 95% CI, 3.54-7.13) were the most significant risk factors. Additional risk factors for early SBO included nonwhite race (aOR, 1.84; 95% CI, 1.33-2.48), increasing age (aOR, 1.04; 95% CI, 1.02-1.05), prior abdominal or pelvic surgery (aOR, 1.49; 95% CI, 1.17-2.03), operating times >170 minutes (aOR, 1.90; 95% CI, 1.37-2.58), uterine weight >250 g (aOR, 1.54; 95% CI, 1.11-2.14), lysis of adhesions (aOR, 2.10; 95% CI, 1.23-3.66), and concurrent appendectomy (aOR, 2.64; 95% CI, 1.06-6.65). CONCLUSION Early SBO is a rare complication of benign hysterectomy. Although route of hysterectomy was not found to be a significant risk factor for early SBO, variables typically associated with abdominal hysterectomy compared to minimally invasive hysterectomy, including higher wound class, larger uteri, and perioperative transfusion (a marker of intraoperative blood loss), were strongly correlated with subsequent development of early obstruction.
Collapse
Affiliation(s)
- David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve School of Medicine, Cleveland, OH.
| | - C Emi Bretschneider
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH; Lerner College of Medicine, Cleveland OH
| | - Sangeeta T Mahajan
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve School of Medicine, Cleveland, OH
| | - Beri Ridgeway
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH; Lerner College of Medicine, Cleveland OH
| | - Abigail Davenport
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH
| | - Robert Pollard
- Case Western Reserve School of Medicine, Cleveland, OH; Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH
| |
Collapse
|
11
|
Vilz TO, Stoffels B, Strassburg C, Schild HH, Kalff JC. Ileus in Adults. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:508-518. [PMID: 28818187 DOI: 10.3238/arztebl.2017.0508] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 11/21/2016] [Accepted: 02/28/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Ileus is one of the more common suspected diagnoses in everyday clinical practice. The term can refer either to mechanical or to functional ileus. Any physician who takes care of patients can be confronted with these entities; thus, all should be familiar with them and competent in their management. METHODS Recommendations are summarized for the diagnostic evaluation and treatment of ileus of various causes on the basis of a selective literature review. RESULTS The manifestations of ileus and its degree of severity generally depend on the site of blockage. The rule until recently was that a patient with suspected mechanical ileus should be taken to surgery within 12 hours; today, however, ileus-particularly of the small bowel-can often be successfully treated conservatively. Likewise, functional ileus only rarely requires surgery: supportive measures, depending on the etiology, usually suffice. CONCLUSION Proper treatment depends on the timely determination of the pathogenesis (mechanical versus functional) and on close interdisciplinary collaboration. A special challenge is posed by patients with peritoneal involvement with cancer who present with symptoms of ileus, in whom a clear distinction between mechanical and functional causation cannot always be drawn.
Collapse
Affiliation(s)
- Tim O Vilz
- Department of General, Visceral-, Thoracic and Vascular Surgery, Bonn University Hospital; Department of Internal Medicine I, Bonn University Hospital; Department of Radiology, Bonn University Hospital
| | | | | | | | | |
Collapse
|
12
|
Skoglar A, Gunnarsson U, Falk P. Band adhesions not related to previous abdominal surgery - A retrospective cohort analysis of risk factors. Ann Med Surg (Lond) 2018; 36:185-190. [PMID: 30505438 PMCID: PMC6249350 DOI: 10.1016/j.amsu.2018.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 12/17/2022] Open
Abstract
Background Postoperative intra-abdominal adhesion formation is a common cause of small bowel obstruction (SBO). Adhesions causing SBO are classed as either matted adhesions or solitary band adhesions. The aim of this study was to investigate the prevalence of previous abdominal surgery in a cohort of patients operated for bowel obstruction and to analyze the causes of obstruction discovered at surgery. Materials and methods The study was performed at a county hospital with a catchment population of 120 000 inhabitants. Records of operations performed for bowel obstruction over a period of 70 months were retrieved. Results Of the 196 surgical procedures for intestinal obstruction included, 108 (55%) were caused by adhesions. In this group, 42 (39%) were due to solitary band adhesions and 66 (61%) were due to matted adhesions. Ten of 18 male patients (56%) with a solitary obstructing band had not undergone previous abdominal surgery (p < 0.05). In the cohort as a whole, a significant number of surgical procedures were performed for solitary band adhesions in patients without prior history of surgery (p < 0.01). Conclusion In male patients, not only previous abdominal surgery but also other factors appear to increase the risk for bowel obstruction due to a solitary band. For intestinal obstruction caused by matted adhesions, however, previous abdominal surgery is the main risk factor in both genders. Patients with signs of SBO but without previous abdominal surgery should be managed bearing in mind that solitary band adhesion and thereby strangulation may be present regardless of previous surgery or not. Post-operative abdominal adhesions are a common reason for small bowel obstruction. Abdominal adhesions can develop without undergoing previous surgery. Band adhesions occurs without prior surgery – gender seems to be of importance.
Collapse
Affiliation(s)
- Andreas Skoglar
- Surgical and Orthopedic Clinic, Kungälvs Hospital, Region Västra Götaland, Sweden
| | - Ulf Gunnarsson
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Peter Falk
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| |
Collapse
|
13
|
Effectiveness of hyaluronic acid/carboxymethylcellulose in preventing adhesive bowel obstruction after laparoscopic radical cystectomy. Asian J Surg 2018; 42:394-400. [PMID: 30266466 DOI: 10.1016/j.asjsur.2018.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/22/2018] [Accepted: 08/16/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND/OBJECTIVE Adhesive bowel obstruction is one of the most frequent complications after radical cystectomy, prolonging hospital stay and fasting period and increasing medical expenses. This study evaluated the effectiveness of hyaluronic acid/carboxymethylcellulose (HA/CMC) in preventing adhesive bowel obstruction after laparoscopic radical cystectomy. METHODS Randomized, controlled, single-blinded study was performed. Of 76 patients who underwent laparoscopic radical cystectomy for bladder cancer, 38 received HA/CMC instillation and 38 did not. The primary endpoint was the rate of postoperative adhesive bowel obstruction. The secondary endpoint was the rate of other postoperative outcomes. RESULTS None of the patients who received HA/CMC instillation experienced postoperative adhesive bowel obstructions, compared with six (15.79%) patients in the control group (p = 0.025). Of the six patients with ileus, two underwent adhesiolysis. There were no significant differences between the two groups in other postoperative outcomes. CONCLUSION HA/CMC instillation during laparoscopic radical cystectomy may reduce the incidence of postoperative adhesive bowel obstruction without adverse effects.
Collapse
|
14
|
Incidence of Adhesive Bowel Obstruction After Colon Cancer Surgery and its Risk Factors. Ann Surg 2018; 268:114-119. [DOI: 10.1097/sla.0000000000002270] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
15
|
Ten Broek RPG, Krielen P, Di Saverio S, Coccolini F, Biffl WL, Ansaloni L, Velmahos GC, Sartelli M, Fraga GP, Kelly MD, Moore FA, Peitzman AB, Leppaniemi A, Moore EE, Jeekel J, Kluger Y, Sugrue M, Balogh ZJ, Bendinelli C, Civil I, Coimbra R, De Moya M, Ferrada P, Inaba K, Ivatury R, Latifi R, Kashuk JL, Kirkpatrick AW, Maier R, Rizoli S, Sakakushev B, Scalea T, Søreide K, Weber D, Wani I, Abu-Zidan FM, De'Angelis N, Piscioneri F, Galante JM, Catena F, van Goor H. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg 2018; 13:24. [PMID: 29946347 PMCID: PMC6006983 DOI: 10.1186/s13017-018-0185-2] [Citation(s) in RCA: 208] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023] Open
Abstract
Background Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups. Methods The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion. Recommendations Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention. Discussion This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited.
Collapse
Affiliation(s)
- Richard P G Ten Broek
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.,39Department of Surgery, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Pepijn Krielen
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Walter L Biffl
- 4Acute Care Surgery, The Queen's Medical Center, Honolulu, Hawaii USA
| | - Luca Ansaloni
- 3General Emergency and Trauma Surgery, Bufalini hospital, Cesena, Italy
| | - George C Velmahos
- 5Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | | | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM), Unicamp Campinas, São Paulo, Brazil
| | | | | | - Andrew B Peitzman
- 10Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | | | | | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus Haifa, Haifa, Israel
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | - Zsolt J Balogh
- 16Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | | | - Ian Civil
- 18Department of Vascular and Trauma Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Raul Coimbra
- 19Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Mark De Moya
- Trauma, Acute Care Surgery Medical College of Wisconsin/Froedtert Trauma Center Milwaukee, Milwaukee, Wisconsin USA
| | - Paula Ferrada
- 21Virginia Commonwealth University, Richmond, VA USA
| | - Kenji Inaba
- 22Division of Trauma & Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA USA
| | - Rao Ivatury
- 21Virginia Commonwealth University, Richmond, VA USA
| | - Rifat Latifi
- 23Department of General Surgery, Westchester Medical Center, Westchester, NY USA
| | - Jeffry L Kashuk
- 24Department of General Surgery, Assuta Medical Centers, Tel Aviv, Israel
| | | | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Sandro Rizoli
- 27Trauma & Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Boris Sakakushev
- 28Department of General Surgery, University of Medicine Plovdiv, Plovdiv, Bulgaria
| | - Thomas Scalea
- 29R Adams Crowley Shock Trauma Center, University of Maryland, Baltimore, USA
| | - Kjetil Søreide
- 30Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,31Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Dieter Weber
- 32Department of General Surgery, Royal Perth Hospital, The University of Western Australia and The University of Newcastle, Perth, Australia
| | - Imtiaz Wani
- 33Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Fikri M Abu-Zidan
- 34Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Nicola De'Angelis
- 35Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | | | - Joseph M Galante
- 37Trauma and Acute Care Surgery and Surgical Critical Care Trauma, Department of Surgery, University of California, Davis, USA
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore hospital, Parma, Italy
| | - Harry van Goor
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
16
|
Hiatt MJ, Casey MJ, Lynch HT, Snyder CL, Stacey M, Walters RW. Efficacy of proximal colectomy for surgical management of right-sided first colorectal cancer in Lynch Syndrome mutation carriers. Am J Surg 2017; 216:99-105. [PMID: 29153248 DOI: 10.1016/j.amjsurg.2017.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/19/2017] [Accepted: 11/02/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND This study analyzes the occurrence of colorectal cancer (CRC) in Lynch syndrome (LS) mutation carriers, interval until diagnosis of metachronous CRC, and survival after proximal colectomy (PC) compared with total (TC) and subtotal colectomy (STC) for right-sided first CRC in LS mutation carriers. METHODS Sixty-four LS mutation carriers with right-sided first CRC treated with PC or TC + STC were confirmed by clinical records. Bivariate analyses were examined for significance and life tables were generated for risk of metachronous CRC and survival estimates following surgery. RESULTS One of 16 (6.3%) mutation carriers treated with TC + STC developed subsequent CRC compared with 13/48 (27%) treated by PC. There was no significant difference in survival estimates between PC compared with TC + STC through 25 years after surgery. CONCLUSION Risk of subsequent CRC and survival estimates following PC and TC + STC should be considered in surgical management of right-sided first CRC in LS mutation carriers.
Collapse
Affiliation(s)
- Molly J Hiatt
- Creighton Hereditary Cancer Center, Department of Preventive Medicine and Public Health, Creighton University, School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA; Department of Obstetrics and Gynecology, Gynecologic Oncology, Creighton University, School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
| | - Murray Joseph Casey
- Creighton Hereditary Cancer Center, Department of Preventive Medicine and Public Health, Creighton University, School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA; Department of Obstetrics and Gynecology, Gynecologic Oncology, Creighton University, School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA.
| | - Henry T Lynch
- Creighton Hereditary Cancer Center, Department of Preventive Medicine and Public Health, Creighton University, School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
| | - Carrie L Snyder
- Creighton Hereditary Cancer Center, Department of Preventive Medicine and Public Health, Creighton University, School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
| | - Mark Stacey
- Creighton Hereditary Cancer Center, Department of Preventive Medicine and Public Health, Creighton University, School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, Creighton University, School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
| |
Collapse
|
17
|
Suwa K, Ushigome T, Ohtsu M, Narihiro S, Ryu S, Shimoyama Y, Okamoto T, Yanaga K. Risk Factors for Early Postoperative Small Bowel Obstruction After Anterior Resection for Rectal Cancer. World J Surg 2017; 42:233-238. [DOI: 10.1007/s00268-017-4152-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
18
|
Prevention of internal hernias and pelvic adhesions following laparoscopic left-sided colorectal resection: the role of fibrin sealant. Surg Endosc 2016; 31:3048-3055. [PMID: 28039651 DOI: 10.1007/s00464-016-5328-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 10/31/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant diseases. This growing experience has also resulted in more reports of postoperative complications from the minimally invasive approach to primary colorectal resection. Small bowel obstruction from internal hernias and pre-sacral adhesions is an uncommon but not negligible complication. However, there is little literature specific to this topic with recommendations for different methods to prevent it. We report our original technique of closing the mesenteric defect and covering the pre-sacral fascia by using fibrin sealant to prevent this complication. METHODS From January 2005 to December 2014, a total of 1079 patients underwent elective laparoscopic left colorectal resection (left hemicolectomy or anterior rectal resection) in our department. In the first 298 procedures, the mesenteric defect was left open, while in the following 781 procedures, it was closed using fibrin sealant with the aim of preventing postoperative small bowel obstruction. RESULTS Among the first 298 patients, three (1%) required reoperation for small bowel obstruction due to internal hernia (0.33%) or critical pre-sacral adhesions (0.66%). These complications did not occur in the subsequent series in which all 781 patients were treated with fibrin sealant prophylactic closure of the mesenteric defect. CONCLUSION In our experience, fibrin sealant closure of the mesenteric defect has demonstrated to be safe and effective in preventing postoperative small bowel obstruction that remains a complication both in open and in laparoscopic colorectal surgeries.
Collapse
|
19
|
Artis T, Artis AS, Arslan E, Mutlu F, Akay A, Deniz K. Preventive Effect of Ethyl Pyruvate on Postoperative Adhesion Formation Following Abdominal Surgery. J INVEST SURG 2016; 29:260-5. [DOI: 10.3109/08941939.2016.1149639] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
20
|
Sakari T, Sjödahl R, Påhlman L, Karlbom U. Role of icodextrin in the prevention of small bowel obstruction. Safety randomized patients control of the first 300 in the ADEPT trial. Colorectal Dis 2016; 18:295-300. [PMID: 26934850 DOI: 10.1111/codi.13095] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/23/2015] [Indexed: 01/11/2023]
Abstract
AIM Adhesions are the most common cause of small bowel obstruction (SBO). The costs of hospitalization and surgery for SBO are substantial for the health-care system. The adhesion-limiting potential of icodextrin has been shown in patients undergoing surgery for gynaecological diseases. A randomized, multicentre trial in colorectal cancer surgery started in 2009 with the aim of evaluating whether icodextrin could reduce the long-term risk of surgery for SBO. Because of some concerns about complications (especially anastomotic leakage) after icodextrin use, a preplanned interim analysis of morbidity and mortality was conducted. METHOD Patients with colorectal cancer without metastasis were randomized 1:1 to receive standard surgery, with or without instillation of icodextrin in the abdominal cavity. For the first 300 patients, the 30-day follow-up data were collected from the Swedish ColoRectal Cancer Registry (SCRCR). Pre-, per- and postoperative data, morbidity and mortality were analysed. RESULTS Of the 300 randomized patients, 288 had a data file in the SCRCR. Twelve patients did not have cancer and another five did not have a resection, leaving 283 for analysis. The authors were blinded to the randomization groups. Demographic data were similar in both groups. The overall complication rate was 24% in Group 1 and 23% in Group 2 (P = 0.89). Four cases of anastomotic leakage were reported in Group 1 and five were reported in Group 2 (P = 1.0). Mortality, intensive care unit (ICU) stay and re-operations did not differ between the groups. CONCLUSION The pre-planned safety analysis of the first 300 patients enrolled in this randomized trial did not show any differences in adverse effects related to the use of icodextrin. All data were gathered from the SCRCR, giving us a strong message that we can continue to include patients in the trial.
Collapse
Affiliation(s)
- T Sakari
- Department of Surgery, Gävle Hospital and Centre for Research and Development, Uppsala University/Count Council of Gävleborg, Gävleborg, Sweden
| | - R Sjödahl
- Department of Surgery, University Hospital Linköping, Linköping, Sweden
| | - L Påhlman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - U Karlbom
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| |
Collapse
|
21
|
Poehnert D, Abbas M, Kreipe HH, Klempnauer J, Winny M. Evaluation of 4DryField® PH as Adhesion Prevention Barrier Tested in an Optimized Adhesion Model in Rats. Eur Surg Res 2015; 55:341-351. [PMID: 26505616 DOI: 10.1159/000441025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 09/10/2015] [Indexed: 12/08/2022]
Abstract
BACKGROUND Adhesions due to pelvic/abdominal surgery are a common serious pathology possibly entailing severe complications. This study investigates the adhesion prevention capability of the novel starch-based agent 4DryField® PH, which together with saline solution forms a barrier gel. Herein, an optimized adhesion model (OPAM) inducing severe adhesions/agglutinations with high reproducibility was used. METHODS In 19 Lewis rats, a 1 × 2 cm abdominal wall defect was created, the peritoneum of the neighboring cecum was abraded, and both injured areas were approximated by suture. Rats were randomized to control (n = 10) or 4DryField PH treatment (n = 9) groups. Another 8 rats had sham surgery for safety assessment of 4DryField PH. At day 7, the quantity and quality of adhesions were assessed macro-/microscopically and evaluated statistically. RESULTS 4DryField PH treatment significantly reduced the incidence and severity of adhesions as verified by significantly improved adhesion scorings (0.4 vs. 4.5; 1.1 vs. 9). Histology revealed reconstitution of the cecum and abdominal wall including regeneration of the visceral/parietal peritoneum. In sham-operated rats, 4DryField PH did not induce adhesion formation. CONCLUSIONS 4DryField PH gel was highly effective in preventing adhesions. Histologically, the injured cecum and abdominal wall regenerated well in the presence of 4DryField PH. Considering the severity of OPAM trauma, the potential of 4DryField PH to prevent adhesions can be rated excellent.
Collapse
Affiliation(s)
- Daniel Poehnert
- Department of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | | | | | | | | |
Collapse
|
22
|
Mean Platelet Volume/Platelet Count Ratio: A New Diagnostic Parameter for Necrosis in Adhesive Small Bowel Obstruction—A Retrospective Cohort Study. Int Surg 2015. [DOI: 10.9738/intsurg-d-14-00315.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Abdominal adhesions are still one of the most common causes of intestinal obstruction. A major challenge in adhesive small bowel obstruction (SBO) management is to detect ischemia as early as possible to avoid necrosis and resection. Elevated mean platelet volume and decreased platelet count have been associated with worse disease course for various ischemic diseases in many clinical studies. The objective of the current study was to evaluate the predictive value of the mean platelet volume/platelet count ratio for patients with small bowel obstruction. Data for patients with adhesive small bowel obstruction, admitted to the general surgery department of Dicle University Hospital between November 2010 and March 2014, were reviewed retrospectively. Mean platelet volume (MPV)/platelet count (PC) ratio values, demographic data, vital signs, and laboratory blood test results of the patients were analyzed. Mean platelet volume/platelet count ratio was higher in bowel necrosis group, while there were no differences between the groups in terms of mean platelet volume values. Mean platelet volume and mean platelet volume/platelet count ratio was higher in patients who underwent surgical treatment. The cutoff value with the highest sensitivity and specificity for MPV/PC ratio was 0.02855 (sensitivity 68%, specificity 65%) for predicting bowel necrosis in patients with adhesive SBO. Mean platelet volume/platelet count ratio is associated with the failure of the conservative management and the presence of bowel necrosis in patients with adhesive small bowel obstruction.
Collapse
|
23
|
Correa-Rovelo JM, Villanueva-López GC, Medina-Santillan R, Carrillo-Esper R, Díaz-Girón-Gidi A. [Intestinal obstruction secondary to postoperative adhesion formation in abdominal surgery. Review]. CIR CIR 2015; 83:345-51. [PMID: 26116038 DOI: 10.1016/j.circir.2015.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 07/03/2014] [Indexed: 01/09/2023]
Abstract
The development of intestinal obstruction after upper and lower abdominal surgery is part of the daily life of each every surgeon. Despite this, there are very few good quality studies that allow enable assessment of the frequency of intestinal obstruction to be assessed, even although postoperative adhesions are the cause of considerable direct and indirect morbidity and its prevention can be considered a public health problem. And yet, in Mexico, at this time, there is no validated recommendation validated on the prevention of adhesions, or more particularly, in connection with the use of a variety of anti-adhesion commercial products which have been marketed for at least a decade. Intraperitoneal adhesions develop between surfaces without peritoneum of the abdominal organs, mesentery, and abdominal wall. The most common site of adhesions is between the greater omentum and anterior abdominal wall previous. Despite the frequency of adhesions and their direct and indirect consequences, just there is only one published a recommendation (from gynaecological literature), regarding peritoneal adhesion prevention. As regards of colorectal surgery, performed more than 250,000 colorectal resections are performed annually in the United States, and from 24% to 35% of them will develop a complication. The clinical and economic financial burden of these complications is enormous, and surgeries colorectal surgery been specifically highlighted as a potential point prevention point of surgical morbidity.
Collapse
Affiliation(s)
| | | | - Roberto Medina-Santillan
- Departamento de Investigación y Posgrado, Escuela Superior de Medicina IPN, México, D.F., México
| | - Raúl Carrillo-Esper
- Unidad de Cuidados Intensivos, Hospital y Fundación Clinica Médica Sur, México, D.F., México
| | - Alejandro Díaz-Girón-Gidi
- Residente de Cirugía Genral, Facultad Mexicana de Medicina, Universidad La Salle, México, D.F., México
| |
Collapse
|
24
|
A new poly(1,3-trimethylene carbonate) film provides effective adhesion reduction after major abdominal surgery in a rat model. Surgery 2015; 157:1113-20. [DOI: 10.1016/j.surg.2015.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 02/04/2015] [Accepted: 02/13/2015] [Indexed: 12/08/2022]
|
25
|
Fortin CN, Saed GM, Diamond MP. Predisposing factors to post-operative adhesion development. Hum Reprod Update 2015; 21:536-51. [PMID: 25935859 DOI: 10.1093/humupd/dmv021] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Accepted: 04/07/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Adhesion development is the most common sequelae of intra-abdominal and pelvic surgery and represents a significant, yet poorly understood, cause of morbidity among post-operative patients. It remains unclear, for example, exactly why adhesions form more frequently in certain tissues and/or patients, or at specific locations within them, as opposed to others. This review contributes to the growing knowledge pool by elucidating factors that potentially predispose to the development of adhesions. Given the strong correlation between a hypofibrinolytic state and adhesion formation, this review article will examine not only those factors that have been shown to directly predispose to adhesion development, but also those that are likely do so indirectly by means of altering the coagulation/fibrinolytic profile. METHODS A literature search was performed using the PubMed database for all relevant English language articles up to February 2014. All of the identified articles were reviewed with particular attention to predisposing factors to post-operative adhesion development. In addition, the reference lists of each article were reviewed to identify additional relevant articles. RESULTS Various factors have been shown to directly increase the risk of post-operative adhesion development; namely, certain genetic polymorphisms in the interleukin-1 receptor antagonist, increased estrogen exposure, and endometriosis. In addition, numerous factors are known to increase the risk of fibrosis, therefore likely increasing the risk of adhesion development indirectly. These factors include genetic polymorphisms in plasminogen activator inhibitor-1 and thrombin-activatable fibrinolysis inhibitor, diabetes mellitus, metabolic syndrome, hyperglycemia, obesity, depression, binge alcohol consumption, anti-Parkinsonian medications, oral hormone therapy, pregnancy, and cancer. CONCLUSIONS The literature reviewed in this paper will help to direct future research aimed at understanding the mechanisms that underlie the association of certain factors with adhesion development. This information will be crucial in the creation of adequate preventative and treatment strategies.
Collapse
Affiliation(s)
- Chelsea N Fortin
- Wayne State University, School of Medicine, Detroit, MI 48201, USA
| | - Ghassan M Saed
- Department of Obstetrics and Gynecology, CS Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Medical College of Georgia, Georgia Regents University, Augusta, GA 30912, USA
| |
Collapse
|
26
|
Klaristenfeld DD, McLemore EC, Li BH, Abbass MA, Abbas MA. Significant reduction in the incidence of small bowel obstruction and ventral hernia after laparoscopic compared to open segmental colorectal resection. Langenbecks Arch Surg 2015; 400:505-12. [PMID: 25876737 DOI: 10.1007/s00423-015-1301-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 03/30/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of this study is to assess the incidence of incisional ventral hernia and small bowel obstruction following laparoscopic and open colorectal resection. METHODS A retrospective review was performed of a large database comprising 13 hospitals, serving 3.6 million patients in Southern California. Patients 18 years and older undergoing elective colorectal resection over a 3-year period were included. The crude incidence rates were calculated, and relative risks of ventral hernia and small bowel obstruction were determined using multivariable proportional hazard modeling. RESULTS Four thousand six hundred and thirteen patients underwent 4765 colorectal resections between August 2008 and August 2011. Fifty-nine percent of the cases were performed laparoscopically; the median age was 63 years, and 49% were males. Colorectal carcinoma (45%) and diverticulitis (18%) were the most common indications for surgery. The median follow-up was 2.4 years. Kaplan-Meier estimates of ventral hernia at 1, 2, and 3 years among the open cohort were significantly higher at 10.1, 17.0, and 20.5%, compared to 5.7, 8.7, and 10.8% in the laparoscopic cohort (p < 0.001). Similarly, small bowel obstruction was higher in the open compared to the laparoscopic group (open 10.4, 15.0, and 18.3% vs. laparoscopic 2.7, 4.4, and 5.5%, p < 0.001). Patients undergoing laparoscopic colorectal resection were less likely to develop ventral hernia [adjusted hazard ratio (AHR) 0.64 (95% CI 0.52, 0.80); p < 0.0001] and small bowel obstruction [AHR 0.41 (95% CI 0.31, 0.54); p < 0.0001]. CONCLUSIONS The incidence of incisional ventral hernia and small bowel obstruction is significantly reduced in patients who undergo laparoscopic compared to open colorectal resection.
Collapse
|
27
|
An injured tissue affects the opposite intact peritoneum during postoperative adhesion formation. Sci Rep 2015; 5:7668. [PMID: 25566876 PMCID: PMC4286739 DOI: 10.1038/srep07668] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 12/03/2014] [Indexed: 01/17/2023] Open
Abstract
The pathophysiology of adhesion formation needs to be clarified to reduce the adhesion-related morbidity. The epithelial characteristics of the peritoneum suggest a protective role against adhesion formation, yet how the peritoneum is involved in adhesion formation is not well characterized. We microscopically observed an experimental model of adhesion formation to investigate the effects of an injured tissue on the opposite intact peritoneum. Adhesions were induced between injured and intact hepatic lobes, and the intact peritoneum opposite to the injured tissue was examined for 8 days. The opposite intact peritoneum was denuded of mesothelial cells for 6 hours, and the remnant mesothelial cells changed morphologically for 24 hours. The detachment of mesothelial cells allowed fibrin to attach to the basement membrane of the opposite peritoneum, connecting the two lobes. Moreover, macrophages and myofibroblasts accumulated between the two lobes, and angiogenesis occurred from the opposite intact lobe to the injured lobe. These observations indicate that an injured tissue deprives the opposite intact peritoneum of its epithelial structure and causes fibrous adhesions to the opposite intact tissue. This study implies a possible role of mesothelial cells for barrier function against adhesion formation, that is, keeping mesothelial cells intact might lead to its prophylaxis.
Collapse
|
28
|
Poehnert D, Abbas M, Kreipe HH, Klempnauer J, Winny M. High reproducibility of adhesion formation in rat with meso-stitch approximation of injured cecum and abdominal wall. Int J Med Sci 2015; 12:1-6. [PMID: 25552912 PMCID: PMC4278869 DOI: 10.7150/ijms.8870] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 11/02/2014] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Peritoneal adhesions following surgery are a common, serious pathology with severe complications. Appropriate animal adhesion models are essential for the assessment of adhesion preventing medical devices. This study introduces a variation of an established rat model in which highest degree adhesions are induced with excellent reproducibility (OPAM=optimized peritoneal adhesion model). Thus, this model seems to be eligible to study effects of adhesion preventing devices. METHODS 24 Lewis male rats were divided into four groups (OPAM, WSFX, sham-OPAM, sham-WSFX). The OPAM technique comprised cecal abrasion, creation of an abdominal wall defect plus approximation of injured areas by a suture, which was compared to a setting of lesions without suture fixation (WSFX). All rats were sacrificed at day 7. Macroscopic and histopathological evaluations were performed. RESULTS were statistically analyzed using ANOVA and Dunnett's test. RESULTS In OPAM rats macroscopic analyses revealed a 90% incidence adhesion of cecum to the abdominal wall, all adhesions imposing as complete agglutination. In WSFX animals incidence of adhesions formation was 75%, while in both sham groups there were no adhesions at all. Histology showed the structure of adhesions with merged smooth muscle of colon and skeletal muscle of abdominal wall in all cases. CONCLUSION OPAM technique provides adhesions of injured areas with a better probability than with conventional methods. All OPAM adhesions impressed as highest degree adhesions, i.e. agglutination. Due to high reproducibility in incidence and extend of adhesion formation, the OPAM is recommended for testing of adhesion prevention medical devices.
Collapse
Affiliation(s)
- Daniel Poehnert
- 1. Department of General, Visceral and Transplantation Surgery, Hannover Medical School (MHH), Hannover, Germany
| | - Mahmoud Abbas
- 2. Department of Pathology, Hannover Medical School (MHH), Hannover, Germany
| | | | - Juergen Klempnauer
- 1. Department of General, Visceral and Transplantation Surgery, Hannover Medical School (MHH), Hannover, Germany
| | - Markus Winny
- 1. Department of General, Visceral and Transplantation Surgery, Hannover Medical School (MHH), Hannover, Germany
| |
Collapse
|
29
|
Chaturvedi AA, Lomme RMLM, Hendriks T, van Goor H. Ultrapure alginate anti-adhesion gel does not impair colon anastomotic strength. J Surg Res 2014; 192:432-9. [PMID: 24980857 DOI: 10.1016/j.jss.2014.05.085] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 04/08/2014] [Accepted: 05/29/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ultrapure alginate gel is promising in terms of adhesion prevention. Because anti-adhesive barriers have been shown to disturb healing of bowel anastomoses, the effect of ultrapure alginate gel on the repair of colon anastomoses was studied. MATERIALS AND METHODS In 102 male Wistar rats, a 0.5-cm segment was resected from the descending colon and continuity was restored by an inverted single-layer end-to-end anastomosis. Animals were randomized into a control, an alginate gel, and a sodium hyaluronate carboxymethyl cellulose film group, each n = 34. Half of each group was sacrificed at day 3 and 7 postoperatively. Anastomotic strength was assessed by measuring both bursting pressure and breaking strength. Hydroxyproline content was measured and histologic analysis was performed. The incidence of adhesion and abscess formation was scored at sacrifice. RESULTS No difference in either anastomotic-bursting pressure or breaking strength was found between experimental groups and the controls at any time point. Both the incidence of adhesion formation (35% versus 71%, P = 0.007) and the adhesion score (0.38 versus 0.79, P = 0.009) were significantly lower in the alginate gel group than in the controls. The abscess rate was higher (46% versus 18%, P = 0.030) in the hyaluronate carboxymethyl cellulose group than in the controls and unchanged in the alginate gel group. CONCLUSIONS While reducing adhesion formation, ultrapure alginate gel does not interfere with the development of colonic anastomotic strength during the crucial early healing period.
Collapse
Affiliation(s)
- Ankit A Chaturvedi
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; European Medical Contract Manufacturing B.V, Nijmegen, The Netherlands.
| | - Roger M L M Lomme
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Thijs Hendriks
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
30
|
ten Broek RPG, Issa Y, van Santbrink EJP, Bouvy ND, Kruitwagen RFPM, Jeekel J, Bakkum EA, Rovers MM, van Goor H. Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. BMJ 2013; 347:f5588. [PMID: 24092941 PMCID: PMC3789584 DOI: 10.1136/bmj.f5588] [Citation(s) in RCA: 325] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To estimate the disease burden of the most important complications of postoperative abdominal adhesions: small bowel obstruction, difficulties at reoperation, infertility, and chronic pain. DESIGN Systematic review and meta-analyses. DATA SOURCES Searches of PubMed, Embase, and Central, from January 1990 to December 2012, without restrictions to publication status or language. STUDY SELECTION All types of studies reporting on the incidence of adhesion related complications were considered. DATA EXTRACTION AND ANALYSIS The primary outcome was the incidence of adhesive small bowel obstruction in patients with a history of abdominal surgery. Secondary outcomes were the incidence of small bowel obstruction by any cause, difference in operative time, enterotomy during adhesiolysis, and pregnancy rate after abdominal surgery. Subgroup and sensitivity analyses were done to study the robustness of the results. A random effects model was used to account for heterogeneity between studies. RESULTS We identified 196 eligible papers. Heterogeneity was considerable for almost all meta-analyses. The origin of heterogeneity could not be explained by study design, study quality, publication date, anatomical site of operation, or operative technique. The incidence of small bowel obstruction by any cause after abdominal surgery was 9% (95% confidence interval 7% to 10%; I(2)=99%). the incidence of adhesive small bowel obstruction was 2% (2% to 3%; I(2)=93%); presence of adhesions was generally confirmed by emergent reoperation. In patients with a known cause of small bowel obstruction, adhesions were the single most common cause (56%, 49% to 64%; I(2)=96%). Operative time was prolonged by 15 minutes (95% confidence interval 9.3 to 21.1 minutes; I(2)=85%) in patients with previous surgery. Use of adhesiolysis resulted in a 6% (4% to 8%; I(2)=89%) incidence of iatrogenic bowel injury. The pregnancy rate after colorectal surgery in patients with inflammatory bowel disease was 50% (37% to 63%; I(2)=94%), which was significantly lower than the pregnancy rate in medically treated patients (82%, 70% to 94%; I(2)=97%). CONCLUSIONS This review provides detailed and systematically analysed knowledge of the disease burden of adhesions. Complications of postoperative adhesion formation are frequent, have a large negative effect on patients' health, and increase workload in clinical practice. The quantitative effects should be interpreted with caution owing to large heterogeneity. REGISTRATION The review protocol was registered through PROSPERO (CRD42012003180).
Collapse
Affiliation(s)
- Richard P G ten Broek
- Department of Surgery, Radboud University Nijmegen Medical Center, PO Box 9101, 6500 HB Nijmegen, Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Hoogenboom FJ, Bosker RJI, Groen H, Meijerink WJHJ, Lamme B, Pierie JPEN. Laparoscopic and open subtotal colectomies have similar short-term results. Dig Surg 2013; 30:265-9. [PMID: 23970165 DOI: 10.1159/000353132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 05/13/2013] [Indexed: 12/10/2022]
Abstract
BACKGROUND Laparoscopic subtotal colectomy (STC) is a complex procedure. It is possible that short-term benefits for segmental resections cannot be attributed to this complex procedure. This study aims to assess differences in short-term results for laparoscopic versus open STC during a 15-year single-institute experience. METHODS We reviewed consecutive patients undergoing laparoscopic or open elective or subacute STC from January 1997 to December 2012. RESULTS Fifty-six laparoscopic and 50 open STCs were performed. The operation time was significantly longer in the laparoscopic group, median 266 min (range 121-420 min), compared to 153 min (range 90-408 min) in the open group (p < 0.001). Median hospital stay showed no statistical difference, 14 days (range 1-129 days) in the laparoscopic and 13 days (range 1-85 days) in the open group. Between-group postoperative complications were not statistically different. CONCLUSIONS Laparoscopic STC has short-term results similar to the open procedure, except for a longer operation time. The laparoscopic approach for STC is therefore only advisable in selected patients combined with extensive preoperative counseling.
Collapse
Affiliation(s)
- Froukje J Hoogenboom
- Department of Surgery, Medical Centre Leeuwarden and the Leeuwarden Institute of Minimally Invasive Surgery Leeuwarden, Groningen, The Netherlands
| | | | | | | | | | | |
Collapse
|
32
|
Rajab TK, Kimonis KO, Ali E, Offodile AC, Brady M, Bleday R. Practical implications of postoperative adhesions for preoperative consent and operative technique. Int J Surg 2013; 11:753-6. [PMID: 23962663 DOI: 10.1016/j.ijsu.2013.07.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 05/02/2013] [Accepted: 07/29/2013] [Indexed: 11/20/2022]
Abstract
Adhesions complicate most intra-peritoneal operations. Once adhesions have formed, patients are at life-long risk for complications that include small bowel obstruction, increased risks during subsequent operations and female infertility. This has two implications for the daily work of surgeons. On the one hand, surgeons need to include the risks from adhesions during pre-operative consent. On the other hand, surgeons need to use operative techniques that minimize adhesions. Therefore this review focuses on the practical implications of adhesions for preoperative consent and operative technique.
Collapse
Affiliation(s)
- Taufiek Konrad Rajab
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | | | | | | | | | | |
Collapse
|
33
|
ten Broek R, Kok- Krant N, Bakkum E, Bleichrodt R, van Goor H. Different surgical techniques to reduce post-operative adhesion formation: a systematic review and meta-analysis. Hum Reprod Update 2012; 19:12-25. [DOI: 10.1093/humupd/dms032] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
|
34
|
Deerenberg EB, Mulder IM, Ditzel M, Slieker JC, Bemelman WA, Jeekel J, Lange JF. Polyvinyl alcohol hydrogel decreases formation of adhesions in a rat model of peritonitis. Surg Infect (Larchmt) 2012; 13:321-5. [PMID: 22789109 DOI: 10.1089/sur.2011.108] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Adhesion formation after surgery for peritonitis-related conditions, with such associated complications as intestinal obstruction, pain, and infertility, remains an important problem. Applying a liquid barrier intra-peritoneally might reduce initial adhesion formation. METHODS A combination of the cecal ligation and puncture model of peritonitis with the side-wall defect (SWD) model of adhesion formation was performed. Forty rats were assigned randomly to receive no barrier or 1 mL or 2 mL of the cross-linked polyvinyl alcohol and carboxymethylcellulose (PVA/CMC) hydrogel A-Part(®) Gel (B. Braun Aesculap AG, Tuttlingen, Germany). After 14 days, the animals were sacrificed, and adhesion formation and abscess formation were scored. RESULTS Thirty animals survived, distributed equally among the groups. There were significantly fewer adhesions to the SWD in the PVA/CMC groups (median 0) than in the control group (median 26%-50%) (p<0.05). The median tenacity of the adhesions was significantly higher in the control group (Zühlke score 2) than in the PVA/CMC groups (Zühlke score 0) (p<0.05). The amount and size of intra-abdominal abscesses were not significantly different in the three groups. CONCLUSION In this experiment, PVA/CMC hydrogel reduced the amount of adhesions to the SWD and between viscera significantly with equal risk of abscess formation.
Collapse
Affiliation(s)
- Eva B Deerenberg
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
35
|
Doorly MG, Senagore AJ. Pathogenesis and clinical and economic consequences of postoperative ileus. Surg Clin North Am 2012; 92:259-72, viii. [PMID: 22414412 DOI: 10.1016/j.suc.2012.01.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Postoperative ileus is a preventable disease with surprising economic consequences. Understanding the triad of dysmotility in conjunction with an enhanced recovery program improves patient outcome, decreases length of stay in hospital, and lowers the cost. Alvimopan and other investigational promotility medications can help attain these goals. Surgeons should avoid labeling all postoperative abdominal distention as ileus, which not only prevents timely diagnosis and treatment of early postoperative small bowel obstruction or acute colonic pseudo-obstruction but also increases patient morbidity and mortality.
Collapse
|
36
|
Ouaïssi M, Gaujoux S, Veyrie N, Denève E, Brigand C, Castel B, Duron JJ, Rault A, Slim K, Nocca D. Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature. J Visc Surg 2012; 149:e104-14. [PMID: 22261580 DOI: 10.1016/j.jviscsurg.2011.11.006] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Post-operative adhesions after gastrointestinal surgery are responsible for significant morbidity and constitute an important public health problem. The aim of this study was to review the surgical literature to determine the incidence, consequences and the variety of possible countermeasures to prevent adhesion formation. METHODS A systematic review of English and French language surgical literature published between 1995 and 2009 was performed using the keywords "adhesion" and "surgery". RESULTS Peritoneal adhesions are reported as the cause of 32% of acute intestinal obstruction and 65-75% of all small bowel obstructions. It is estimated that peritoneal adhesions develop after 93-100% of upper abdominal laparotomies and after 67-93% of lower abdominal laparotomies. Nevertheless, only 15-18% of these adhesions require surgical re-intervention. The need for re-intervention for adhesion-related complications varies depending on the initial type of surgery, the postoperative course and the type of incision. The laparoscopic approach appears to decrease the risk of adhesion formation by 45% and the need for adhesion-related re-intervention to 0.8% after appendectomy and to 2.5% after colorectal surgery. At the present time, only one product consisting of hyaluronic acid applied to a layer of carboxymethylcellulose (Seprafilm(®)) has been shown to significantly reduce the incidence of postoperative adhesion formation; but this product is also associated with a significant increase in the incidence of anastomotic leakage when the membrane is applied in direct contact with the anastomosis. The use of this product has not been shown to decrease the risk of re-intervention for bowel obstruction. CONCLUSIONS The prevention of postoperative adhesions is an important public health goal, particularly in light of the frequency of this complication. The routine use of anti-adhesion products is not recommended given the lack of studies with a high level of evidence concerning their efficacy and safety of use.
Collapse
Affiliation(s)
- M Ouaïssi
- Service de chirurgie digestive et viscérale, hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Shin JY. Risk factors of early postoperative small bowel obstruction following a proctectomy for rectal cancer. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2011; 27:315-21. [PMID: 22259747 PMCID: PMC3259428 DOI: 10.3393/jksc.2011.27.6.315] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Accepted: 09/08/2011] [Indexed: 12/24/2022]
Abstract
Purpose 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. Methods 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. Results 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. Conclusion 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.
Collapse
Affiliation(s)
- Jin Yong Shin
- Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| |
Collapse
|
38
|
Hellebrekers BWJ, Kooistra T. Pathogenesis of postoperative adhesion formation. Br J Surg 2011; 98:1503-16. [DOI: 10.1002/bjs.7657] [Citation(s) in RCA: 148] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2011] [Indexed: 01/13/2023]
Abstract
Abstract
Background
Current views on the pathogenesis of adhesion formation are based on the ‘classical concept of adhesion formation’, namely that a reduction in peritoneal fibrinolytic activity following peritoneal trauma is of key importance in adhesion development.
Methods
A non-systematic literature search (1960–2010) was performed in PubMed to identify all original articles on the pathogenesis of adhesion formation. Information was sought on the role of the fibrinolytic, coagulatory and inflammatory systems in the disease process.
Results
One unifying concept emerged when assessing 50 years of studies in animals and humans on the pathogenesis of adhesion formation. Peritoneal damage inflicted by surgical trauma or other insults evokes an inflammatory response, thereby promoting procoagulatory and antifibrinolytic reactions, and a subsequent significant increase in fibrin formation. Importantly, peritoneal inflammatory status seems a crucial factor in determining the duration and extent of the imbalance between fibrin formation and fibrin dissolution, and therefore in the persistence of fibrin deposits, determining whether or not adhesions develop.
Conclusion
Suppression of inflammation, manipulation of coagulation as well as direct augmentation of fibrinolytic activity may be promising antiadhesion treatment strategies.
Collapse
Affiliation(s)
- B W J Hellebrekers
- Department of Obstetrics and Gynaecology, Haga Teaching Hospital, The Hague, The Netherlands
| | - T Kooistra
- TNO Prevention and Health, Department of Biosciences, Gaubius Laboratory, Leiden, The Netherlands
| |
Collapse
|
39
|
Incidence of small bowel obstruction after laparoscopic and open colon resection. Am J Surg 2011; 201:411-5; discussion 415. [DOI: 10.1016/j.amjsurg.2010.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Revised: 09/08/2010] [Accepted: 09/08/2010] [Indexed: 11/22/2022]
|
40
|
Schnüriger B, Barmparas G, Branco BC, Lustenberger T, Inaba K, Demetriades D. Prevention of postoperative peritoneal adhesions: a review of the literature. Am J Surg 2011; 201:111-21. [PMID: 20817145 DOI: 10.1016/j.amjsurg.2010.02.008] [Citation(s) in RCA: 170] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 02/16/2010] [Accepted: 02/16/2010] [Indexed: 12/24/2022]
Abstract
BACKGROUND postoperative adhesions are a significant health problem with major implications on quality of life and health care expenses. The purpose of this review was to investigate the efficacy of preventative techniques and adhesion barriers and identify those patients who are most likely to benefit from these strategies. METHODS the National Library of Medicine, Medline, Embase, and Cochrane databases were used to identify articles related to postoperative adhesions. RESULTS ileal pouch-anal anastomosis, open colectomy, and open gynecologic procedures are associated with the highest risk of adhesive small-bowel obstruction (class I evidence). Based on expert opinion (class III evidence) intraoperative preventative principles, such as meticulous hemostasis, avoiding excessive tissue dissection and ischemia, and reducing remaining surgical material have been published. Laparoscopic techniques, with the exception of appendicitis, result in fewer adhesions than open techniques (class I evidence). Available bioabsorbable barriers, such as hyaluronic acid/carboxymethylcellulose and icodextrin 4% solution, have been shown to reduce adhesions (class I evidence). CONCLUSIONS postoperative adhesions are a significant health problem with major implications on quality of life and health care. General intraoperative preventative techniques, laparoscopic techniques, and the use of bioabsorbable mechanical barriers in the appropriate cases reduce the incidence and severity of peritoneal adhesions.
Collapse
Affiliation(s)
- Beat Schnüriger
- Los Angeles County Medical Center, University of Southern California, Department of Surgery, Division of Acute Care Surgery, Trauma, Emergency Surgery and Surgical Critical Care, LAC + USC Medical Center, Room 1105, 1200 North State St, Los Angeles, CA, USA
| | | | | | | | | | | |
Collapse
|
41
|
Brüggmann D, Tchartchian G, Wallwiener M, Münstedt K, Tinneberg HR, Hackethal A. Intra-abdominal adhesions: definition, origin, significance in surgical practice, and treatment options. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:769-75. [PMID: 21116396 DOI: 10.3238/arztebl.2010.0769] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 12/08/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intra-abdominal adhesions arise after more than 50% of all abdominal operations and are an important source of postoperative complications. They attach normally separated organs to each other and can cause major problems for the affected patients by giving rise to small bowel obstruction, chronic pelvic pain, dyspareunia, infertility, and higher complication rates in subsequent operations. They are also a frequent source of medicolegal conflict. Thus, every physician should be familiar with their mechanism of origin, their consequences, and the methods by which they can be prevented. METHODS A selective PubMed/Medline search from 1960 onward as well as articles to which these publications referred. The expert consensus position of the European Society for Gynaecological Surgery is also taken into consideration. RESULTS Adhesions arise through aberrant wound healing after peritoneal injury with further influence from a variety of other factors. Preventive measures include minimizing peritoneal injury intraoperatively through the meticulous observance of basic surgical principles, moistening the mesothelium to keep it from drying out, irrigating the peritoneal cavity to remove blood and clot, and keeping the use of intra-abdominal foreign material to a minimum. CONCLUSION Adhesions are an inevitable consequence of intra-abdominal surgery. They can be prevented to some extent with meticulous surgical technique and certain other measures. For operations carrying a high risk of postoperative adhesions, e.g., surgery on the adnexa or bowel, commercially available peritoneal instillates or barrier methods can be used to limit adhesion formation.
Collapse
Affiliation(s)
- Dörthe Brüggmann
- CARE Group (Clinical Adhesion Research and Evaluation Group), Klinik für Gynäkologie und Geburtshilfe, Justus-Liebig-Universität Gießen, Germany
| | | | | | | | | | | |
Collapse
|
42
|
Barmparas G, Branco BC, Schnüriger B, Lam L, Inaba K, Demetriades D. The incidence and risk factors of post-laparotomy adhesive small bowel obstruction. J Gastrointest Surg 2010; 14:1619-28. [PMID: 20352368 DOI: 10.1007/s11605-010-1189-8] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 02/23/2010] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The purpose of this review was to assess the incidence and risk factors for adhesive small bowel obstruction (SBO) following laparotomy. METHODS The PubMed database was systematically reviewed to identify studies in the English literature delineating the incidence of adhesive SBO and reporting risk factors for the development of this morbidity. RESULTS A total of 446,331 abdominal operations were eligible for inclusion in this analysis. The overall incidence of SBO was 4.6%. The risk of SBO was highly influenced by the type of procedure, with ileal pouch-anal anastomosis being associated with the highest incidence of SBO (1,018 out of 5,268 cases or 19.3%), followed by open colectomy (11,491 out of 121,085 cases or 9.5%). Gynecological procedures were associated with an overall incidence of 11.1% (4,297 out of 38,751 cases) and ranged from 23.9% in open adnexal surgery, to 0.1% after cesarean section. The technique of the procedure (open vs. laparoscopic) also played a major role in the development of adhesive SBO. The incidence was 7.1% in open cholecystectomies vs. 0.2% in laparoscopic; 15.6% in open total abdominal hysterectomies vs. 0.0% in laparoscopic; and 23.9% in open adnexal operations vs. 0.0% in laparoscopic. There was no difference in SBO following laparoscopic or open appendectomies (1.4% vs. 1.3%). Separate closure of the peritoneum, spillage and retention of gallstones during cholecystectomy, and the use of starched gloves all increase the risk for adhesion formation. There is not enough evidence regarding the role of age, gender, and presence of cancer in adhesion formation. CONCLUSION Adhesion-related morbidity comprises a significant burden on healthcare resources and prevention is of major importance, especially in high-risk patients. Preventive techniques and special barriers should be considered in high-risk cases.
Collapse
Affiliation(s)
- Galinos Barmparas
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Los Angeles County Medical Center-University of Southern California, 1200 North State Street, Inpatient Tower (C)-Room C5L100, Los Angeles, CA 90033, USA
| | | | | | | | | | | |
Collapse
|
43
|
Rajab TK, Ahmad UN, Kelly E. Implications of late complications from adhesions for preoperative informed consent. J R Soc Med 2010; 103:317-21. [PMID: 20610617 DOI: 10.1258/jrsm.2010.090378] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The process of informed consent is a critical aspect of the doctor-patient relationship. Doctors have a professional duty to provide patients with sufficient information if a treatment is associated with a significant risk. NHS guidelines advise doctors to mention risks that occur more frequently than 1-2% or risks that are serious even if the likelihood is very small. In the case of abdominal and pelvic surgery, risks can broadly be divided into early and late complications. Early complications, such as bleeding and infection, have a close temporal relationship with the operation. Such complications are routinely mentioned during the consent process. In contrast, postoperative adhesions cause changes in the normal anatomy that can adversely affect function many years and even decades after the original operation, leaving patients at lifelong risk for late complications. These late adhesive complications, namely bowel obstruction, mechanical female infertility and chronic pain, are often neglected during the consent process. However, the risks to patients from late adhesive complications are serious and well in excess of the accepted threshold where it could be considered a breach in the duty of care not to inform patients. This is reflected by a number of claims against the NHS based on consent issues regarding late adhesive complications of surgery. Therefore, late complications of surgery from adhesions should be included in the pre-operative consent process. This would decrease litigation costs but more importantly also underpins the doctor-patient relationship.
Collapse
Affiliation(s)
- Taufiek Konrad Rajab
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School 75 Francis Street, Boston, MA 02115, USA.
| | | | | |
Collapse
|
44
|
Rajab TK, Wallwiener M, Talukdar S, Kraemer B. Adhesion-related complications are common, but rarely discussed in preoperative consent: a multicenter study. World J Surg 2009; 33:748-50. [PMID: 19194740 DOI: 10.1007/s00268-008-9917-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Peritoneal adhesions are recognized as an important cause for patient morbidity, but complications related to adhesions occur relatively late after the original operation. Therefore preoperative consent may not adequately reflect the proportions of the problem. METHODS A total of 200 patients admitted for intraperitoneal operations at six hospitals were prospectively reviewed to identify whether adhesion-related complications were documented as possible adverse events in their respective consent forms. RESULTS Adhesion-related complications were documented in 8.5% (n=17) of consent forms (bowel obstruction n=8, requirement for further operations n=5, difficult reoperation n=1, pain n=3). A direct relationship with adhesions was noted in n=9 of these consent forms. CONCLUSIONS Preoperative informed consent does not adequately reflect the magnitude of adhesion-related problems. These findings have immediate implications for clinical practice.
Collapse
Affiliation(s)
- Taufiek Konrad Rajab
- Department of Surgery, Central Middlesex Hospital, Imperial College London, London, NW10 7NS, UK.
| | | | | | | |
Collapse
|
45
|
Kumar S, Wong PF, Leaper DJ. Intra-peritoneal prophylactic agents for preventing adhesions and adhesive intestinal obstruction after non-gynaecological abdominal surgery. Cochrane Database Syst Rev 2009:CD005080. [PMID: 19160246 DOI: 10.1002/14651858.cd005080.pub2] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Intra-abdominal adhesions are common and challenge patients, surgeons and other healthcare providers. They are potentially preventable and several agents that act as barriers between adjacent peritoneal surfaces have been evaluated for prophylaxis. Efficacy, judged by systematic reviews, has only been undertaken in gynaecological surgery. OBJECTIVES To determine efficacy and safety of peritoneal adhesion prophylaxis on incidence, distribution and adhesion-related intestinal obstruction after non-gynaecological surgery. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials, the Cochrane Colorectal Cancer Group specialised register, MEDLINE (1966-2008), and EMBASE (1971-2008) were searched. SELECTION CRITERIA Blinded and non-blinded, randomised and quasi-randomised clinical trials were considered. DATA COLLECTION AND ANALYSIS Two authors individually conducted the searches and assessed the quality of studies for inclusion which were analysed using the Revman Analyses software 5.0.0 provided by the Cochrane collaboration. Meta-analysis used a random effects model. MAIN RESULTS Seven randomised trials were eligible; six compared hyaluronic acid/carboxymethyl membrane (HA/CMC) and one 0.5% ferric hyaluronate gel against controls.HA/CMC reduced the incidence of adhesions (OR 0.15 (95% CI: 0.05, 0.43); p=0.0005) with reduced extent (WMD -25.9% (95% CI: -40.56, -11.26); p=0.0005) and severity. There was no reduction of intestinal obstruction needing surgical intervention (odds ratio: 0.84 (95% CI: 0.24, 2.7) with comparable overall morbidity and mortality.The study of 0.5% ferric hyaluronate gel was prematurely terminated and no valid conclusions could be made but there was a higher incidence of overall morbidity (OR 5.04; 95% CI: 1.1, 22.9) and ileus (OR: 9.29; 95% CI: 1.57, 54.77; p=0.01). IMPLICATIONS FOR PRACTICE There is evidence that the use of HA/CMC membrane reduces incidence, extent and severity of adhesions which may, theoretically, have implications in re-operative abdominal surgery. There is no evidence that the incidence of intestinal obstruction or need for operative intervention is reduced. HA/CMC appears to be safe but there may be a risk of leak when wrapped around an anastomoses. HA/CMC may be considered for intra-abdominal, adhesion prophylaxis at a surgeon's discretion and clinical context. IMPLICATIONS FOR RESEARCH Further research is needed to explore the effectiveness of other agents in abdominal surgery in general. Synergism, using agents which target different aspects of adhesiogenesis, with exploration effectiveness in a wide range of emergency and elective surgery should be considered. Longer term outcomes of recurrent intestinal obstruction and chronic pain, identification of high risk groups of patients with evaluation of cost-effectiveness are required.
Collapse
Affiliation(s)
- Senthil Kumar
- Directorate of Surgery, Queens Hospital, Rom Valley way, Romford, Essex, UK, RM7 0AG.
| | | | | |
Collapse
|
46
|
Rajab TK, Wallwiener M, Planck C, Brochhausen C, Kraemer B, Wallwiener CW. A direct comparison of seprafilm, adept, intercoat, and spraygel for adhesion prophylaxis. J Surg Res 2008; 161:246-9. [PMID: 19375716 DOI: 10.1016/j.jss.2008.11.839] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2008] [Revised: 11/15/2008] [Accepted: 11/18/2008] [Indexed: 11/24/2022]
Abstract
BACKGROUND Commercially available agents for adhesion prophylaxis are legion but there is a lack of direct comparisons between them. Here we compare four of the most commonly used adhesion barriers against a control group in a clinically relevant rat model. MATERIAL AND METHODS Standardized lesions were created in Wistar rats using electrocautery and suturing. Subsequently, the experimental lesions were treated with Seprafilm (n = 30), Adept (n = 30), Intercoat (n = 30), Spraygel (n = 30), or no barrier (n = 30). The resulting adhesions were examined 14 d postoperatively. RESULTS The mean area covered by adhesion was 77% in the control group, 46% in animals treated with Seprafilm, 54% in animals treated with Adept, 55% in animals treated with Intercoat, and 68% in animals treated with Spraygel. The adhesion-free incidence was 20% (n = 6) of lesions treated with Seprafilm, 20% (n = 6) of lesions treated with Intercoat, 3% of lesions treated with Spraygel (n = 1), and 0% of lesions treated with Adept or the control group. CONCLUSIONS There were statistically significant differences between the barriers with regards to the area covered by adhesions and the adhesion-free incidence. In spite of this, a significant adhesion burden remains with all of the tested barriers.
Collapse
|
47
|
Shin JY, Hong KH. Risk Factors for Early Postoperative Small-Bowel Obstruction After Colectomy in Colorectal Cancer. World J Surg 2008; 32:2287-92. [DOI: 10.1007/s00268-008-9652-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
48
|
Adhesions are common and costly after open pouch surgery. J Gastrointest Surg 2008; 12:1239-45. [PMID: 18278539 DOI: 10.1007/s11605-008-0481-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Accepted: 01/16/2008] [Indexed: 01/31/2023]
Abstract
PURPOSE Open ileal pouch surgery leads to high rates of adhesive small-bowel obstruction (SBO). A laparoscopic approach may reduce these complications. We aimed to review the incidence of adhesive SBO-related complications after open pouch surgery and to model the potential financial impact of a laparoscopic approach purely as an adhesion prevention strategy. MATERIALS AND METHODS We reviewed cases of open ileal pouch patients kept on a database and examined annually. Case notes were studied for episodes of adhesive SBO requiring admission or reoperation. Similar parameters were studied in a small series undergoing laparoscopic pouch surgery. The financial burden of the open access complications was estimated and potential financial impact of a laparoscopic approach modeled. RESULTS Two hundred seventy-six patients were followed up after open surgery (median, 6.3; range, 0.2-20.1 years). There were 76 (28%) readmissions (median length of stay, 7.4 days) in 53 patients (19%) and 28 (10%) reoperations (43% within 1 year). Laparoscopic patients required less adhesiolysis at second-stage surgery (0% vs 36%, p < 0.0001) and had less SBO episodes within 12 months of surgery (0% vs 14%, p < 0.0001) than open patients. Modeling a laparoscopic approach cost $1,450 and saved $3,282, thus netting $1,832 per pouch constructed. CONCLUSION Open ileal pouch surgery results in significant cumulative long-term access-related complications, particularly adhesions. These impose a large medical burden on patients and financial burden on health-care systems, all of which may be recouped by a laparoscopic approach, despite higher theater costs.
Collapse
|
49
|
Hare NC, Arnott ID, Satsangi J. Therapeutic options in acute severe ulcerative colitis. Expert Rev Gastroenterol Hepatol 2008; 2:357-70. [PMID: 19072385 DOI: 10.1586/17474124.2.3.357] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Ulcerative colitis is a relapsing-remitting inflammatory disease affecting the colon and is associated with considerable morbidity. In acute severe attacks, there continues to be an associated mortality rate of 1-2%, even in specialist units. During an acute severe exacerbation, approximately two-thirds of patients will respond to intravenous corticosteroid therapy, the accepted first-line therapy in such cases. For steroid-refractory patients, options are limited to surgery (colectomy) or second-line agents, such as ciclosporin or infliximab, used in an attempt to salvage the colon. Considerable debate exists over the optimal management of such patients. During the last decade, an increased understanding of the pathogenesis of inflammatory bowel disease has led to the rapid development of other biological agents, such as basiliximab and visilizumab. Novel methods, such as leucopheresis, have been studied and other established immunomodulatory agents, such as tacrolimus, have also been suggested. The purpose of this review is to highlight some of the areas of recent development in the treatment of acute severe ulcerative colitis and review important safety data, with a particular emphasis on biological agents.
Collapse
Affiliation(s)
- Nicola C Hare
- Gastrointestinal Unit, Molecular Medicine Centre, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU, UK.
| | | | | |
Collapse
|
50
|
Abstract
Mechanical obstruction of the small bowel and colon is moderately common, accounting for several hundred thousand admissions per year in the United States. Patients generally present with abdominal pain, nausea and emesis, abdominal distention, and progressive obstipation. Clinical findings of high fever, localized severe abdominal tenderness, rebound tenderness, severe leukocytosis, or metabolic acidosis suggest possible complications of bowel necrosis, bowel perforation, or generalized peritonitis. Differentiation of total mechanical obstruction from partial mechanical obstruction and pseudo-obstruction is important because total mechanical obstruction is generally treated surgically,whereas the other two entities are usually treated medically. Mechanical obstruction is usually suggested by plain abdominal radiographs, and confirmed by small bowel follow through,abdominal CT, or CT enteroclysis.
Collapse
Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, MOB 233, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
| | | |
Collapse
|