Laparoscopic treatment of acute adhesive small bowel obstruction compared with conventional method

Laparoscopic treatment of acute adhesive small bowel obstruction compared with conventional method

Osama Mahmoud, MD; FRCS; Mohamed Mahfouz, MD;

Amr Hefny, MD;  Mohamed Attia, MD

Department of General Surgery,  Ain Shams University, Cairo, Egypt.

Abstract

Abstract: Intestinal obstTUction is an abdominal emergency, and it is a common reason for surgical referral. There are many studies that demonstrated  the feasibility of laparoscopy  in management of acute adhesive small bowel obstruction. Although laparoscopy is a good technique for many intra-abdominal operative procedures, laparoscopy was contraindicated in abdominal surgical emergency, and intestinal obstTUction. It remains unclear whether patients with acute small bowel obstruction  (SBO) might benefit  from this technique  or not. 104 patients were included in this study and were divided into two groups, each group included 52 patients. Each group was treated by one surgical technique from those mentioned above and the results were compared  with each other. Complete laparoscopic treatment  was performed  in 25 patients (48.1%). Major intra-operative complications occurred in 15 patients in the LAP group and 8 patients in CONV group (p= 0.156). Intra-operative perforations were more frequent inpatients who had more than one previous laparotomy (P=O.066). Postoperative complications occurred in 10 patients  (19.2%)  in the LAP group  and in 21 patients  (40.4%),  who had conventional surgery (P=0.032). Bowel movements started 3.5 days after operation in the LAP group, and

4.4 days after conventional operation (P=O.001). The length of hospital stay was 11.3 and 18.1 days respectively (P=0.001). From this study we can conclude than laparoscopic treatment of acute SBO was feasible in about half of these patients, morbidity is lower, hospital stay is shorter than patients with open surgery, and postoperative recovery and resumption of a normal diet is faster, but the risk of intra-operative complications increased. A laparoscopic approach seems justified in subset of patients.

Key words: LAP (laparoscopic surgery), CONV (conventional  surgery), SBO (small bowel

obstTUction).

Introduction:

Adhesions following abdominal and pelvic surgery is important in view of their morbidity and frequent hospital re-admission. Patients

with intra-peritoneal adhesions may develop chronic symptoms or present acutely with intestinal obstruction. Acute adhesive intestinal obstruction  is the most common reason for emergency admission and re-admission to hospital. The obstruction is almost always in the small bowel, although the level of obstruction varies. The condition is readily diagnosed by the clinical symptoms and signs and abdominal plain film (erect and supine). Although  the indication for  laparoscopic

surgery in elective surgery has broadened, it is not generally accepted in emergencies.l-3

Patients for whom laparoscopy was initially considered to be contraindicated, were those with history of previous surgery or with suspected intra-abdominal adhesions or bowel obstruction.2,4,5 However these types of procedures have been treated increasingly with laparoscopic approach  as experience has grown.6,7 Some  surgeons recommend laparoscopic surgery for many reasons, such as less intra-abdominal adhesions than open surgery, and postoperative quicker recovery of intestinal motility,12,13 So this approach has therefore  been used for some small bowel

obstruction (SBO)  who might benefit  from these advantages. Acute obstruction may be associated with a higher risk of bowel injury and limited exposure due to severe abdominal distension than elective  adhesiolysis. Some series have demonstrated the feasibility and safety  of laparoscopic treatment for  acute SBQ,16,21 and suggested advantages  for this procedure.However, comparative data on the laparoscopic and conventional treatment  of acute SBO are lacking. The present study was therefore undertaken to compare the results of laparoscopic surgery for acute SBO with those of   conventional  surgical  treatment.

Patients and methods:

Inthis study 52 patients who presented with SBO  were  operated on  laparoscopically, between January 2004  and  July  2009,  in Demerdash hospital, Cairo, Egypt. The results were compared  retrospectively with similar number of patients who presented also by SBO and treated conventionally. Operative results and outcome of these patients were analyzed retrospectively and compared  with those of conventionally treated series in matched pair analysis. Variables evaluated were operating time, reason  for conversion, intra-operative and postoperative complications, length  of hospital stay  and  bowel  movements after surgery. Selection of patients for the matched­ pair analysis included consideration of the number of previous laparotomies, the duration of  symptoms, age  and  sex.  Patients were included only if clinical symptoms were acute and the obstruction was confirmed at operation to be caused by adhesions.Patients with other conditions, such  as incarcerated hernia  or carcinoma of the caecum, were identified at operation  and were excluded. The indication for laparoscopy was assessed individually by the operating surgeons according to the duration of symptoms, degree of abdominal distension, and personal experience. Insertion of 1st trocar was done under direct vision using an open technique. The incision was made distant to any previous scars. After creation of pneumo­ peritoneum additional trocars  were  placed according to the intra-abdominal findings. All patients received standard prophylactic antibiotic, a nasogastric tube  and  urinary

catheter. For statistical analysis, patients were divided into  three  groups. The  LAP group comprised all patients for whom laparoscopy was intended, including those operations which were converted. The cLAP  group  included those patients who  had  a completely laparoscopic procedure, and the conventional group comprised matched pair patients who had open operation.  The student (t test) was used to compare the results between different groups. Equality of variance was evaluated using the Leviene test, p <0.05 was considered significant.

Results:

The  LAP  and  CONV groups were comparable in age, sex, number of previous laparotomies and  duration of symptoms Table(l). Previous  operations were mostly appendicectomies and gynecological operations followed by previous intestinal obstruction, cholecystectomy and colonic resection. Fifty two patients underwent laparoscopy for acute SBO.  Conversion to open surgery was necessary in 27 patients 51% Table(2). Compete laparoscopic treatment was performed in 25 patients. Operative  time was longer in LAP group  than the CONV group (103 and

84 min; P >0.05). Whereas the operating time in the cLAP group was comparable to that of conventional surgery  (83 versus 84). Major intra-operative complications occurred in 15 patients 28.8% in the LAP group and 8 patients

15% in the CONV group (P=O.l56) Table(3).

Complications  occurred in 10 patients during laparoscopy and another 5 patients after conversion to  open  surgery. Perforations occurred in 2 patients, and one  patient developed hemorrhage. Serosal tears occurred in 4 patients  in the LAP group  and 3 in the CONV group. The  number of previous laparotomies was identified as a risk factor for intra-operative complications. Major  intra­ operative  complication occurred in 11 of 26 patients with two  or  more previous laparotomies compared with 4 of26 with fewer laparotomies (P=0.066). The  duration of symptoms had no influence on the complication rate. Patients  in the LAP group had quicker recovery of bowel  movements (P <0.001), shorter  time  for  hospital stay  (P <0.001),

Table( 4),  and  fewer  postoperative complications than those who  had  a conventional procedure Table(5). Two patients

developed anastomotic leak and were treated by  laparotomy with resection and reconstruction  of   the    anastomosis.

Table (1): Patients' characteristics.

Table (1): Reasons of conversion to open surgery.

Table (3): Intraoperative major complications during laparoscopic and conventional treatment of  acute small bowel obstruction.

Table (4): Postoperative results.

Table (5): Postoperative complications.

Discussion:

Laparoscopic surgery for acute SBO was

1st described by Bastug et al.6,7 And since this time  many  studies were  done  to evaluate different techniques dealing with  that pathology, although many studies were done on that issue.The studies comparing the results of laparoscopic and conventional treatment are lacking. The conversion  rate was 51.99% in this  study  which  was  slightly higher  than previous reported values of about 45%.21,24,25

The main  reason for conversion was an obscured view due to intestinal distension.7;10;16

A reduced field of vision together with the vulnerability of the bowel limits the use of laparoscopy and may explain why laparoscopy for acute SBO has the highest rate of conversion in laparoscopic surgery.27

There is evidence that  laparoscopic treatment of acute SBO leads to a higher rate of bowel injury than conventional  surgery.25

The rate of bowel perforation in this series was

26.9%  in the LAP  group. All perforations occurred during adesiolysis and were not related to trocar insertion, indicating that openinsertion of the 1st trocar can be performed safely. The incidence of perforation was higher  in this series than reported values 25.5%.7,20;11,25 For laparoscopic procedures the 5 perforations that occurred after conversion demonstrates the vulnerability  of the bowel and complexity of adhesion in these patients. On the other hand, no perforation or recurrent obstruction was missed in this series. Although intra-operative bowel perforation did  not  worsen the postoperative course,  the incidence during laparoscopic treatment was nearly twice that of conventional open operation, and perforation

was significantly more common  in patients with two or more previous laparotomies. The number  of laparotomies and complexity of operation are known to increase postoperative adhesion  formation.29,30 Although postoperative complications have been shown to occur more frequently after converted procedure  than after complete laparoscopic surgery of  SB0;7,25  complications after laparoscopic and conventional surgery have not  been  compared. In  the  present study, patients in whom laparascopic treatment was intended had fewer postoperative complications, quicker recovery of  bowl movements and a shorter  hospital  stay than conventionally treated patients. Bailey et al,28 have also shown a shorter hospital stay after laparoscopic surgery compared with  open management of acute SBO. An advantage with regard to bowel movements has been described previously only for laparoscopically treated patients compared with those whose operations

for acute SBO were converted.24 In the present

study laparoscopic treatment of acute SBO led to a shorter period of postoperative ileus than open  treatment,  even when conversion was included laparoscopic treatment of  acute adhesive SBO was feasible in half of these patients, who  benefited from a low postoperative complication rate,  a quicker recovery of  bowel  function and  a shorter hospital stay.  An  attempt at  laparoscopic management of acute SBO seems justified in patients with fewer than  two  previous laparotomies but should not be offered to other patients because of the unacceptably high risk of   intra-operative  bowel perforation.

Conclusion:

Laparoscopic adhesiolysis for small bowel obstruction  is feasible but can be convenient only  if  performed by  skilled surgeons in selected patients. The laparoscopic adhesiolysis for small bowel obstruction is satisfactorily carried out when early indicated in patients with a low number of laparotomies resulting in a short hospital stay  and  a lower postoperative morbidity. Although  a higher small bowel obstruction recurrence remains the major postoperative risk of the laparoscopic management of these patients.

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