'Let's just wait one more day': impact of timing on surgical outcome in the treatment of adhesion-related small bowel obstruction

Controversy exists but most surgeons agree that surgical treatment for failed conservative management of adhesion-related small bowel obstruction (SBO) should be within 48 hours. However, many find themselves delaying definitive treatment in the hopes of resolution. Our aim was to determine what impact timing has on surgical outcomes of SBO. A retrospective review of all consecutive patients surgically treated for adhesion-related SBO was performed from January 2001 to August 2006. Study groups included patients treated emergently (less than 6 hours), expeditiously (6 to 48 hours), and delayed (greater than 48 hours). Laparoscopic, open, and converted treatment types were controlled for as confounding variables using analysis of variance. Outcome measures were return of bowel function after surgery (RBF), length of stay after surgery (LOS), and morbidity. There were 27 emergencies, 30 treated expeditiously, and 34 delayed. Groups were matched in age and gender. RBF after surgery was significantly longer for those delayed in treatment compared with those treated expeditiously (greater than 48 hours = 7.4 days vs less than 6 hours = 7.6 and 6 to 48 hours = 5.4; P < .05) as well as LOS after surgery (greater than 48 hours = 12.3 days vs less than 6 hours = 10.1 and 6 to 48 hours = 7.6; P < 0.05). Patients treated with laparoscopy within 6 to 48 hours had a significantly shorter RBF and LOS than any other combination of timing and treatment. Postoperative morbidity was higher in the delayed group (79%) than the other groups (44% emergent and 40% expeditious) (P < 0.05). There was one death in the delayed group. Delaying surgical treatment beyond 48 hours for SBO is common and results in worse outcomes and longer LOS. Laparoscopic treatment within 48 hours is superior to open treatment.

Auto-Cross-Linked Hyaluronic Acid Gel Does Not Reduce Intra-Abdominal Adhesions or Abscess Formation in a Rat Model of Peritonitis

BACKGROUND

Prevention of adhesion and abscess formation would decrease mortality and morbidity after peritonitis. In this study the effect of a new anti-adhesive, auto-cross-linked hyaluronic acid polysaccharide (ACP) gel, on adhesion and abscess formation was studied in a rat peritonitis model.

MATERIALS AND METHODS

In experiment 1, bacterial peritonitis was induced in 24 Wistar rats, using a cecal ligation and puncture model. Animals were randomized to receive 4 mL ACP gel (4%) or 4 mL phosphate buffered saline (PBS). After 2 weeks animals were killed and adhesions and abscesses were scored. In experiment 2, 72 rats underwent the same procedure but were randomized to receive 2 mL ACP gel, 4 mL ACP gel, or 4 mL PBS. After 1 and 3 weeks, respectively, half of the animals in each group were killed and adhesions and abscesses were scored.

RESULTS

The median total adhesion score was 12 (range, 3-20) in the ACP group and was 9 (range, 6-12) in the PBS group (not significant) in experiment 1. 91% of rats in the ACP group developed abscesses, versus 90% in the control group. There were no significant differences in abscess size or number of abscesses. In experiment 2, total adhesion scores in the 2 mL ACP group, 4 mL ACP group, and PBS group were 4 (range, 2-20), 6 (range, 1-11), and 6 (range, 1-18), respectively, (not significant) after 1 week and 3.5 (range, 1-8), 5 (range, 2-15), and 4 (range, 0-9), respectively, (not significant) after 3 weeks. All rats in the 2 mL ACP group and the PBS group and 83% of the 4 mL ACP group had developed abscesses after 1 week. After 3 weeks these percentages were 80, 75, and 73, respectively. There were no significant differences in size or number of abscesses between groups both after 1 and 3 weeks.

CONCLUSION

ACP does not reduce adhesion and abscess formation in a rat peritonitis model.

Survival and complication rates in 300 horses undergoing surgical treatment of colic. Part 3: Long-term complications and survival

REASONS FOR PERFORMING STUDY

Few studies have evaluated long-term survival and complication rates in horses following surgical treatment of colic, making it difficult to offer realistic advice concerning long-term prognosis.

OBJECTIVE

To review the complications occurring after discharge from hospital and survival to >12 months after surgery of 300 horses undergoing exploratory laparotomy for acute colic. Pre-, intra- and post operative factors that affected long-term complications and long-term survival were assessed.

METHODS

History, clinical findings, surgical findings and procedures and post operative treatments of 300 consecutive surgical colic cases (1994-2001) were reviewed. Long-term follow-up information was retrieved from case records and telephone enquiries from owners.

RESULTS

The long-term (>12 months) survival rate for 204 horses discharged after colic surgery and for which follow-up information was available was 84%. The most common complication after discharge was colic, affecting 35.1% of horses following a single laparotomy. Colic was most common in horses that had had small intestinal obstructions, bowel resection or post operative ileus. Abdominal adhesions were most common in horses that presented with severe colic due to strangulation of small intestine. Ventral hernia formation occurred in 8% of horses, and was most common in horses that had had post operative wound drainage or infection.

CONCLUSIONS

This study identified various factors that appear to predispose horses to long-term complications after colic surgery.

POTENTIAL RELEVANCE

Further evaluation of strategies that might reduce the incidence of such complications are needed; in particular, the value of intraperitoneal heparin should be evaluated, and procedures designed to reduce the rates of wound drainage and infection assessed.

Adhesion intestinal obstruction in children in northern Nigeria

In developing countries, reports on adhesion intestinal obstruction in children are scanty. We report 30 children managed for adhesion intestinal obstruction during a 16-year period. The age range was 10 weeks-14 years (median 9 years). There were 24 boys and 6 girls. Postoperative adhesion was the cause in 13 (43%) patients, inflammatory in 11 (37%), and in 5 (17%) no cause could be identified. In one patient, adhesion followed missed ileal perforation from blunt abdominal trauma. Duration of symptoms was 1-21 days (median 4 days). Only four of the 13 patients with postoperative adhesion obstruction were managed conservatively initially, but this failed in all; one was found to have an intestinal perforation at laparotomy. The remaining nine had immediate laparotomy owing to presence of features of strangulation at presentation; two required intestinal resection for gangrene. All other patients had laparotomy soon after resuscitation. The resection rate for gangrene was 13% and 3% required closure of perforations. Postoperatively six (20%) patients developed eight infective complications. There was recurrence in three of 27 (11%) surviving patients within 3 months. Mortality was three (10%). The presentation of adhesion intestinal obstruction in children in northern Nigeria is late and morbidity and mortality are high. Early presentation should improve the outcome.

Dialysate hyaluronan concentration predicts survival but not peritoneal sclerosis in continuous ambulatory peritoneal dialysis

Hyaluronan is an important component of extracellular matrix and plays a critical role in early phases of wound healing. Peritoneal mesothelium is a major site of hyaluronan production. Serum hyaluronan concentration has been shown to predict survival in maintenance hemodialysis patients. We hypothesize that mesothelial production of hyaluronan during the stable phase of continuous ambulatory peritoneal dialysis (CAPD) predicts the risk of peritoneal adhesion and mortality. We studied peritoneal dialysate effluent (PDE) hyaluronan levels from 116 stable CAPD patients. They were then followed-up for 3 years. During the follow-up period, there were 196 episodes of peritonitis in 78 patients. Tenckhoff catheter was removed in 31 episodes (15.8%). Tenckhoff catheter was reinserted successfully in 12 cases, and CAPD was resumed. Peritoneal adhesion developed in 16 cases. Three patients died before Tenckhoff catheter reinsertion was attempted. There was no difference in stable-phase PDE hyaluronan levels between patients who developed peritoneal adhesion and those who did not (159 +/- 63 versus 227 +/- 194 microgram/L, P = 0.27). Thirty-three patients died during the study period. Patients who died had significantly higher PDE hyaluronan concentration than survivors (272 +/- 194 versus 170 +/- 105 microgram/L, P < 0.01). Univariate analysis showed that increased PDE hyaluronan level was associated with a shorter patient survival (P < 0.001). There was no association between PDE hyaluronan level and serum albumin, protein nitrogen appearance, and percentage of lean body mass. Multivariate analysis confirmed that PDE hyaluronan level, serum albumin, and diabetic state were independent predictors of survival. We conclude that PDE hyaluronan level during stable phase of CAPD does not predict the risk of postperitonitis adhesion. However, it is a strong independent predictor of survival in CAPD patients.

Development of a novel glucose polymer solution (icodextrin) for adhesion prevention: pre-clinical studies

Intra-abdominal adhesion formation causes significant post-operative morbidity. Controlled studies using animal models have been carried out to assess the tolerability and preventive efficacy of icodextrin solution (a biodegradable, biocompatible, glucose polymer). Reduction of adhesion formation was first evaluated in a rabbit double uterine horn model, applying 10-75 ml of 7.5 and 20%, or 50 ml of 2.5-20% icodextrin solution post-operatively. Significant increases in adhesion free sites (P < 0.005) were observed with volumes > or =25 ml, and at concentrations > or =4%. Efficacy of 50 ml 4 and 20% icodextrin was then evaluated both during and after surgery, demonstrating significant reductions in adhesion formation (P < 0. 002). In one study, intra- plus post-operative use of 4% icodextrin produced the greatest reduction of non-surgical site adhesions; in others, the post-operative effect was predominant. Post-surgical administration of 50 ml 4% icodextrin in a rabbit sidewall model also resulted in more adhesion-free animals, and a significant reduction (P < 0.001) in areas of adhesion formation and reformation. In a rat infection potentiation model, 4% icodextrin produced no difference in mortality, abscess formation or overall abscess score. These data suggest that 4% icodextrin offers a well-tolerated and effective means of reducing post-surgical adhesion formation.

Morbidity and mortality of inadvertent enterotomy during adhesiotomy

BACKGROUND

Inadvertent enterotomy is a feared complication of adhesiotomy during abdominal reoperation. The nature and extent of this adhesion-associated problem are unknown.

METHODS

The records of all patients who underwent reoperation between July 1995 and September 1997 were reviewed retrospectively for inadvertent enterotomy, risk factors were analysed using univariate and multivariate parameters, and postoperative morbidity and mortality rates were assessed.

RESULTS

Inadvertent enterotomy occurred in 52 (19 per cent) of 270 reoperations. Dividing adhesions in the lower abdomen and pelvis, in particular, caused bowel injury. In univariate analysis body mass index was significantly higher in patients with inadvertent enterotomy (mean(s.d.) 25.5(4.6) kg/m2 ) than in those without enterotomy (21.9(4.3) kg/m2 ) (P < 0.03). Patient age and three or more previous laparotomies appeared to be independent parameters predicting inadvertent enterotomy (odds ratio (95 per cent confidence interval) 1.9 (1.3-2.7) and 10.4 (5.0-21.6) respectively; P < 0.001). Patients with inadvertent enterotomy had significantly more postoperative complications (P < 0.01) and urgent relaparotomies (P < 0.001), a higher rate of admission to the intensive care unit (P < 0.001) and parenteral nutrition usage (P < 0.001), and a longer postoperative hospital stay (P < 0.001).

CONCLUSION

The incidence of inadvertent enterotomy during reoperation is high. This adhesion-related complication has an impact on postoperative morbidity

Abdominal surgery in foals: a review of 119 cases (1977-1994)

The case records of 119 young horses (all less than age one year) that underwent an exploratory celiotomy during a 17 year period were examined to determine the surgical findings, short- and long-term outcome, and prevalence of small intestinal disease compared to previous reports in the mature horse. Physical and laboratory values were compared for long-term survivors vs. nonsurvivors and the frequency of post operative intra-abdominal adhesions was determined. The most common cause for exploratory celiotomy was small intestinal strangulation, followed by enteritis and uroperitoneum. Six horses died during surgery, 23 were subjected to euthanasia at the time of surgery due to a grave prognosis, and 17 horses died or were destroyed after surgery, prior to discharge from the hospital; the short-term survival was 61%. Nine horses were lost to follow-up. Forty-one horses survived long-term (at least 6 months after surgery), 15 died or were subjected to euthanasia after discharge for reasons related to the prior abdominal surgery, and 8 died or were destroyed after discharge due to unrelated reasons, making the long-term survival 45%. Fifty-three (45%) of the horses presented as neonates, and 66 (55%) presented age 3-12 months. Uroperitoneum and meconium impaction were the most common disease in the neonate. Intussusception and enteritis were the most common diseases in older foals. The overall prevalence of small intestinal disease was 44%. Significant elevations in packed cell volume, heart rate, nucleated cell counts and total protein in abdominal fluid and rectal temperature were observed in nonsurvivors compared to survivors. Nonsurvivors had significantly decreased serum bicarbonate, chloride, sodium, and venous pH values. There was no evidence that location of the lesion affected long-term survival. Horses with a simple obstruction had a higher survival percentage than those with a strangulating obstruction, and horses that underwent an intestinal resection had a lower long-term survival than those horses undergoing only intestinal manipulation. Nineteen (33%) of the foals examined after the original surgery had evidence of intra-abdominal adhesions. Nine of these (16%) had adhesions that caused a clinical problem.

[Malignant neoplasms and intestinal obstruction in children 3 to 15 years old]

Observations on one of the rare complications in children presenting malignant neoplasms of the abdominal cavity and retroperitoneal space are described. Over a 7-year period, operative treatment is undertaken in 42 children aged 3 to 15 years. In eleven of them (26.42 per cent) it is a matter of mechanical ileus. The type of bowel obstruction in the series of children under study is a follows: obturation-in three and adhesion-in five cases. The obturation involves the large intestine, and is due to pressure of a neoplastic process in advanced stage of development on the colon. Ileus due to adhesions occurs after operative removal of the neoplastic formation. The essential differences in type of intestinal obstruction in children with malignant neoformation in the abdominal region from the one in adult patients justify the report on the observations.

Retrospective analysis of the results of 151 exploratory laparotomies in horses with gastrointestinal disease

Of 149 horses that underwent 151 exploratory laparotomies for gastrointestinal disorders from September 1987 to May 1991, 107 (72%) were discharged from the hospital: 100 (66%) survived for > 7 months, 94 of which returned to their intended use. Survival rate (64/80) for horses with caecum/large colon obstruction was significantly (P = 0.003) higher than for horses with small intestinal obstruction (33/64). Prolonged surgery was associated with significantly (P < 0.001) lower survival rates than short surgical time. In the large intestine, survival rate (15/29) for strangulated obstructions was significantly (P < 0.001) lower than for simple obstructions (52/58). Generalised septic peritonitis (9 horses) and bowel obstruction associated with adhesions (8 horses) were the most frequent fatal post-operative complications. The rate (6/44) of post-operative adhesions after small intestinal obstruction was significantly (P = 0.006) higher than that (2/68) following large intestinal obstruction. The rate (8/55) of post-operative adhesion formation in horses that required enterotomy/enterectomy was significantly (P = 0.003) higher than that (0/57) in horses that did not require gut wall incisions. Incisional suppuration developed in 42 horses and occurred with a significantly (P = 0.028) higher rate (32/72) after caecum/large colon lesions than after obstruction at other sites, (10/42) but was not associated with known contamination at the time of surgery (P = 0.806).

Treatment and outcome of right colon cancers adherent to adjacent organs or the abdominal wall

Fifty-four (4%) of 1284 patients treated for adenocarcinoma of the colon and rectum during a 10-year period ending in 1989 underwent potentially curative resection of right colon lesions found during surgery to be adherent to adjacent organs, abdominal wall, or retroperitoneum. Final pathologic staging was as follows: modified Dukes' class B1 (n = 2), B2 (n = 24), C1 (n = 1), and C2 (n = 27). Thirteen (24%) patients had postoperative complications, including two (3.7%) with sepsis. One patient died after surgery (mortality, 1.9%). Survival rates at 1, 3, and 5 years were 74%, 52%, and 37%, respectively. Only one (11%) of nine patients with pancreatic or duodenal adherence treated with limited resection was free of disease during follow-up. Adjuvant radiation therapy and chemotherapy did not improve survival. Histologic depth of tumor penetration could not be predicted by intraoperative assessment, and therefore radical resection is recommended whenever possible.

Nationwide investigations of intestinal obstruction in Japan

Two nationwide questionnaire surveys of intestinal obstruction in Japan were undertaken, covering two two-year periods, from January, 1975 to December, 1976 and from January, 1985 to December, 1986, respectively. The findings of a comparative review of these two surveys indicated that although the overall mortality of intestinal obstruction had not changed between 1975/76 and 1985/86, being 6.8 per cent and 6.5 per cent, respectively, simple adhesive obstruction had decreased from 3.2 per cent in 1975/76 to 2.0 per cent in 1985/86. The main cause of adhesion was laparotomy and in cases of both simple adhesive obstruction and strangulation adhesive obstruction, the rate of adhesion secondary to laparotomy of the upper gastrointestinal tract and colon and rectum had increased between 1975/76 and 1985/76. Obstructions caused by neoplasms had increased from 8.2 per cent in 1975/76 to 10.0 per cent in 1985/86, while those caused by adhesions had increased further still, from 42.5 per cent in 1975/76 to 60.8 per cent in 1985/86. Among the latter group, non-operatively treated cases had increased, which may be accounted for by the fact that facilities which adopt non-operative treatment using intestinal decompression as the first choice for simple adhesive obstruction cases have increased. In both surveys, the mortality of cases receiving nonoperative treatment was lower than that of operative cases.

Prognostic factors in patients with stage I epithelial ovarian cancer

We analyzed factors predictive of relapse risk in patients with stage I invasive epithelial ovarian cancer: 252 patients from the Princess Margaret Hospital provided a data base for hypothesis generation, and data on 267 patients from the Norwegian Radium Hospital were used for hypothesis testing. The outcomes in most analyses in the two series were very similar, validating the following conclusions. Differentiation (grade) was the most powerful predictor of relapse, followed by dense adherence (which resulted in outcomes equivalent to those in stage II) and, finally, large-volume ascites. When the effects of these three factors were accounted for, then none of the following were prognostic: bilaterality (stage Ib), cyst rupture (stage Ic), capsular penetration (stage Ic), tumor size, histologic subtype, patient age, year of diagnosis, and postoperative therapy. These results allow simplification of stage I substaging, as only differentiation, dense adherence, and large-volume ascites (? peritoneal cytology) need be considered. The 5-year relapse-free rate was 98% in patients with grade 1 tumors in whom both dense adherence and large-volume ascites were absent. These patients are adequately treated by operation alone. Although the relapse risk was high enough in the remaining patients to warrant postoperative treatment, a significant benefit could be shown only for a small subset of patients, namely those with densely adherent tumors treated with abdominopelvic radiotherapy. In grades 2 and 3, none of the therapies used in either series was superior to pelvic radiotherapy or operation alone.

The role of feces, necrotic tissue, and various blocking agents in the prevention of adhesions

Ischemic tissue and intraperitoneal bacteria have been ascribed an etiologic role in the production of intra-abdominal adhesions. To further elucidate the role of these stimuli and to evaluate the potential protective effect of various agents, peritonitis was induced in 160 Sprague-Dawley rats. The experiment was stratified into those animals with peritonitis plus necrotic tissue, solid feces, both, or neither. The agents tested were a nonsteroidal anti-inflammatory (ibuprofen), free radical scavenger (SOD), and an anticoagulant (heparin). Death was less likely to occur in animals treated with heparin (3 of 40 vs. 12 of 40, p less than 0.01) or SOD (4 of 40 vs. 12 of 40, p less than 0.05). Ibuprofen did not increase survival in this model. Heparin protected against adhesions in animals with an ischemic ileum of limb and without solid feces. In animals with a nonischemic isolated segment of ileum and solid feces, adhesion formation was increased in both the ibuprofen and the heparin treatment groups (p less than 0.05).

Incidence of postoperative adhesion obstruction following neonatal laparotomy

Of 649 neonates undergoing laparotomy in a 10 year period, 54 (8.3 per cent) developed adhesion related intestinal obstruction requiring surgical treatment. In 16 infants the obstruction followed a period of prolonged postoperative ileus, while the remaining 38 had completely recovered from the previous surgical procedure before the development of obstruction. The adhesion obstruction occurred after a single neonatal laparotomy in 35 cases but the remaining 19 had undergone subsequent laparotomies; 75 per cent of the obstructions developed within 6 months and 90 per cent within 1 year of surgery. The highest risk groups were infants undergoing correction of gastroschisis (15.4 per cent) and malrotation (15 per cent). There were nine deaths, two of which were a direct consequence of the adhesion obstruction.

Intestinal obstruction

One hundred severty-one cases of mechanical intestinal obstruction were studied. One hundred fifteen had small bowel obstruction and fifty-six had large bowel obstruction. Adhesion (32.8 per cent), hernia (21.6 per cent), and neoplasm (18.1 per cent) were the cause of obstruction in more than 70 per cent of all cases. More than 40 per cent of patients were older than 60 years and the average age was 52.7. The numbers of males and females were approximately equal. There were twice as many whites as blacks, and the mortality rate was higher among blacks. The overall uncorrected mortality rate was 18.7 per cent. Operation was performed in 105 patients (61.4 per cent), with a postoperative mortality of 19 per cent and corrected postoperative mortality of 4.5 per cent. Contributing factors that were significant were high incidence of metastatic diseases, elderly patients, and delay in admission.