1
|
Toneman MK, Krielen P, Jaber A, Groenveld TD, Stommel MW, Griffiths EA, Parker MC, Bouvy ND, van Goor H, Ten Broek RP. Predicting long-term risk of reoperations following abdominal and pelvic surgery: a nationwide retrospective cohort study. Int J Surg 2023; 109:1639-1647. [PMID: 37042312 PMCID: PMC10389206 DOI: 10.1097/js9.0000000000000375] [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: 08/29/2022] [Accepted: 03/24/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND The risk of reoperations after abdominal and pelvic surgery is multifactorial and difficult to predict. The risk of reoperation is frequently underestimated by surgeons as most reoperations are not related to the initial procedure and diagnosis. During reoperation, adhesiolysis is often required, and patients have an increased risk of complications. Therefore, the aim of this study was to provide an evidence-based prediction model based on the risk of reoperation. MATERIALS AND METHODS A nationwide cohort study was conducted including all patients undergoing an initial abdominal or pelvic operation between 1 June 2009 and 30 June 2011 in Scotland. Nomograms based on multivariable prediction models were constructed for the 2-year and 5-year overall risk of reoperation and risk of reoperation in the same surgical area. Internal cross-validation was applied to evaluate reliability. RESULTS Of the 72 270 patients with an initial abdominal or pelvic surgery, 10 467 (14.5%) underwent reoperation within 5 years postoperatively. Mesh placement, colorectal surgery, diagnosis of inflammatory bowel disease, previous radiotherapy, younger age, open surgical approach, malignancy, and female sex increased the risk of reoperation in all the prediction models. Intra-abdominal infection was also a risk factor for the risk of reoperation overall. The accuracy of the prediction model of risk of reoperation overall and risk for the same area was good for both parameters ( c -statistic=0.72 and 0.72). CONCLUSIONS Risk factors for abdominal reoperation were identified and prediction models displayed as nomograms were constructed to predict the risk of reoperation in the individual patient. The prediction models were robust in internal cross-validation.
Collapse
Affiliation(s)
- Masja K. Toneman
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen
| | - Pepijn Krielen
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen
| | - Ahmed Jaber
- Department of Surgery, Shamir Medical Center, Be’er Ya’akov, Israel
| | - Tjitske D. Groenveld
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen
| | - Martijn W.J. Stommel
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen
| | - Ewen A. Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham
| | | | - Nicole D. Bouvy
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboudumc, Radboud Institute for Health Sciences, Nijmegen
| | | |
Collapse
|
2
|
Toneman M, Groenveld T, Krielen P, Hooker A, de Wilde R, Torres-de la Roche LA, Di Spiezio Sardo A, Koninckx P, Cheong Y, Nap A, van Goor H, Pargmae P, ten Broek R. Risk Factors for Adhesion-Related Readmission and Abdominal Reoperation after Gynecological Surgery: A Nationwide Cohort Study. J Clin Med 2023; 12:jcm12041351. [PMID: 36835887 PMCID: PMC9965311 DOI: 10.3390/jcm12041351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
More than half of women in developed countries undergo surgery during their lifetime, putting them at risk of adhesion-related complications. Adhesion-related complications include small bowel obstruction, chronic (pelvic) pain, subfertility, and complications associated with adhesiolysis during reoperation. The aim of this study is to predict the risk for adhesion-related readmission and reoperation after gynecological surgery. A Scottish nationwide retrospective cohort study was conducted including all women undergoing a gynecological procedure as their initial abdominal or pelvic operation between 1 June 2009 and 30 June 2011, with a five-year follow-up. Prediction models for two- and five-year risk of adhesion-related readmission and reoperation were constructed and visualized using nomograms. To evaluate the reliability of the created prediction model, internal cross-validation was performed using bootstrap methods. During the study period, 18,452 women were operated on, and 2719 (14.7%) of them were readmitted for reasons possibly related to adhesions. A total of 2679 (14.5%) women underwent reoperation. Risk factors for adhesion-related readmission were younger age, malignancy as indication, intra-abdominal infection, previous radiotherapy, application of a mesh, and concomitant inflammatory bowel disease. Transvaginal surgery was associated with a lower risk of adhesion-related complications as compared to laparoscopic or open surgeries. The prediction model for both readmissions and reoperations had moderate predictive reliability (c-statistics 0.711 and 0.651). This study identified risk factors for adhesion-related morbidity. The constructed prediction models can guide the targeted use of adhesion prevention methods and preoperative patient information in decision-making.
Collapse
Affiliation(s)
- Masja Toneman
- Department of Surgery, Radboudumc, 6525 GA Nijmegen, The Netherlands
- Correspondence:
| | - Tjitske Groenveld
- Department of Surgery, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Pepijn Krielen
- Department of Surgery, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Angelo Hooker
- Department of Obstetrics and Gynecology, Zaans Medical Center (ZMC), 1502 DV Zaandam, The Netherlands
| | - Rudy de Wilde
- University Hospital for Gynecology, Carl von Ossietzky University, 26121 Oldenburg, Germany
| | | | - Atillio Di Spiezio Sardo
- Department of Public Health, School of Medicine, University of Naples Federico II, 80131 Naples, Italy
| | - Philippe Koninckx
- Department of Gynecology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium
| | - Ying Cheong
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- Complete Fertility Centre, Southampton SO16 5YA, UK
| | - Annemiek Nap
- Department of Gynecology, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Pille Pargmae
- Department of Gynecology, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Richard ten Broek
- Department of Surgery, Radboudumc, 6525 GA Nijmegen, The Netherlands
| |
Collapse
|
3
|
van Steensel S, van den Hil LCL, Schreinemacher MHF, ten Broek RPG, van Goor H, Bouvy ND. Adhesion awareness in 2016: An update of the national survey of surgeons. PLoS One 2018; 13:e0202418. [PMID: 30118503 PMCID: PMC6097683 DOI: 10.1371/journal.pone.0202418] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/06/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND AIMS Adhesions, that form in 60-80% of all abdominal operations, can cause complications such as chronic abdominal pain, small-bowel obstruction, female infertility, and the need for adhesiolysis in future surgeries. Our 2010 Adhesion Awareness survey demonstrated that despite the huge clinical impact of adhesions; adhesion-related complications were seldom mentioned in the informed consent. Six years later, a follow-up survey was conducted to assess the progress on awareness on adhesion-related complications in the Netherlands. MATERIAL AND METHODS The 2010 Adhesion Awareness survey was repeated after a literature update. The knowledge regarding adhesions; the use of anti-adhesive agents and involvement in the informed consent process were assessed. Surgeons and surgical trainees were contacted by e-mail. The data was analysed using a Chi-square or Mann-Whitney U test and corrected for multiple testing. RESULTS The response rate was 32.6%, similar to the survey in 2010 (34.4%). 88.1% agreed with the clinical relevance of adhesions, comparable to 2010 (89.8%). The score on the knowledge test was 38.8% (2010: 37.2%). Involvement of adhesion-related complications in the informed consent process increased, although 32.5% almost never mentions adhesions. In 2016, 42.4% reported a correct occurrence of bowel lesions during adhesiolysis, higher than in 2010 (P<0.001). CONCLUSIONS The adhesion awareness did not increase in six years, despite the efforts made. However, an increased awareness regarding adhesiolysis related complications was detected. Improvement of knowledge and behavior is essential to narrowing the gap between the impact of adhesions as a major complication of abdominal surgery and the limited adhesion awareness.
Collapse
Affiliation(s)
- Sebastiaan van Steensel
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Leontine C. L. van den Hil
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | | | | | - Harry van Goor
- Department of General Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nicole D. Bouvy
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
- * E-mail:
| |
Collapse
|
4
|
Abstract
OBJECTIVE To provide a comprehensive review of recent epidemiologic data on the burden of adhesion-related complications and adhesion prevention. Second, we elaborate on economic considerations for the application of antiadhesion barriers. BACKGROUND Because the landmark SCAR studies elucidated the impact of adhesions on readmissions for long-term complications of abdominal surgery, adhesions are widely recognized as one of the most common causes for complications after abdominal surgery. Concurrently, interest in adhesion prevention revived and several new antiadhesion barriers were developed. Although these barriers have now been around for more than a decade, adhesion prevention is still seldom applied. METHODS The first part of this article is a narrative review evaluating the results of recent epidemiological studies on adhesion-related complications and adhesion prevention. In part II, these epidemiological data are translated into a cost model of adhesion-related complications and the potential cost-effectiveness of antiadhesion barriers is explored. RESULTS New epidemiologic data warrant a shift in our understanding of the socioeconomic burden of adhesion-related complications and the indications for adhesion prevention strategies. Increasing evidence from cohort studies and systematic reviews shows that difficulties during reoperations, rather than small bowel obstructions, account for the majority of adhesion-related morbidity. Laparoscopy and antiadhesion barriers have proven to reduce adhesion formation and related morbidity. The direct health care costs associated with treatment of adhesion-related complications within the first 5 years after surgery are $2350 following open surgery and $970 after laparoscopy. Costs are about 50% higher in fertile-age female patients. Application of an antiadhesion barriers could save between $328 and $680 after open surgery. After laparoscopy, the costs impact ranges from $82 in expenses to $63 of savings. CONCLUSIONS Adhesions are an important cause for long-term complications in both open and laparoscopic surgery. Adhesiolysis during reoperations seems to impact adhesion-related morbidity most. Routine application of antiadhesion barriers in open surgery is safe and cost-effective. Application of antiadhesion barriers can be cost-effective in selected cases of laparoscopy. More research is needed to develop barriers suitable for laparoscopic use.
Collapse
|
5
|
Leclercq RMFM, Van Barneveld KWY, Schreinemacher MHF, Assies R, Twellaar M, Bouvy ND, Muris JWM. Postoperative abdominal adhesions and bowel obstruction. A survey among Dutch general practitioners. Eur J Gen Pract 2015; 21:176-82. [DOI: 10.3109/13814788.2015.1055466] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
|
6
|
ten Broek RPG, Strik C, van Goor H. Preoperative nomogram to predict risk of bowel injury during adhesiolysis. Br J Surg 2014; 101:720-7. [PMID: 24723023 DOI: 10.1002/bjs.9479] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Inadvertent bowel injury during adhesiolysis is a major cause of increased morbidity and mortality following abdominal surgery. Identification of risk factors predicting this complication would guide preoperative counselling and surgical decision-making. The aim of this study was to identify predictive preoperative factors for inadvertent bowel injury occurring during adhesiolysis. METHODS All patients undergoing elective abdominal surgery between June 2008 and June 2010 were evaluated prospectively as part of the LAPAD study. Data on adhesiolysis and inadvertent organ injury were gathered by direct observation during operation. Univariable logistic regression was used to investigate factors that increased the risk of inadvertent bowel injury. Independent predictors of bowel injury were identified using multivariable logistic regression and used to create a clinical nomogram. RESULTS Of 715 patients eligible for analysis, 48 (6.7 per cent) had inadvertent bowel injuries. In 42 patients the defect was detected during operation and in nine at a later time (3 patients had both). Bowel resection was required for almost two-thirds of the enterotomies. The number of previous laparotomies, anatomical site of the operation, presence of bowel fistula and laparotomy via a pre-existing median scar were independent predictors of bowel injury. A clinical scoring system was constructed using a nomogram incorporating these risk factors; this had a predictive discrimination, measured as the area under the receiver operating characteristic curve, of 0.85. CONCLUSION A nomogram based on four independent factors predicted the risk of inadvertent bowel injury. REGISTRATION NUMBER NCT01236625 (http://www.clinicaltrials.gov).
Collapse
Affiliation(s)
- R P G ten Broek
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | | | | |
Collapse
|
7
|
Mais V. Peritoneal adhesions after laparoscopic gastrointestinal surgery. World J Gastroenterol 2014; 20:4917-4925. [PMID: 24803803 PMCID: PMC4009523 DOI: 10.3748/wjg.v20.i17.4917] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/11/2014] [Accepted: 02/17/2014] [Indexed: 02/06/2023] Open
Abstract
Although laparoscopy has the potential to reduce peritoneal trauma and post-operative peritoneal adhesion formation, only one randomized controlled trial and a few comparative retrospective clinical studies have addressed this issue. Laparoscopy reduces de novo adhesion formation but has no efficacy in reducing adhesion reformation after adhesiolysis. Moreover, several studies have suggested that the reduction of de novo post-operative adhesions does not seem to have a significant clinical impact. Experimental data in animal models have suggested that CO2 pneumoperitoneum can cause acute peritoneal inflammation during laparoscopy depending on the insufflation pressure and the surgery duration. Broad peritoneal cavity protection by the insufflation of a low-temperature humidified gas mixture of CO2, N2O and O2 seems to represent the best approach for reducing peritoneal inflammation due to pneumoperitoneum. However, these experimental data have not had a significant impact on the modification of laparoscopic instrumentation. In contrast, surgeons should train themselves to perform laparoscopy quickly, and they should complete their learning curves before testing chemical anti-adhesive agents and anti-adhesion barriers. Chemical anti-adhesive agents have the potential to exert broad peritoneal cavity protection against adhesion formation, but when these agents are used alone, the concentrations needed to prevent adhesions are too high and could cause major post-operative side effects. Anti-adhesion barriers have been used mainly in open surgery, but some clinical data from laparoscopic surgeries are already available. Sprays, gels, and fluid barriers are easier to apply in laparoscopic surgery than solid barriers. Results have been encouraging with solid barriers, spray barriers, and gel barriers, but they have been ambiguous with fluid barriers. Moreover, when barriers have been used alone, the maximum protection against adhesion formation has been no greater than 60%. A recent small, randomized clinical trial suggested that the combination of broad peritoneal cavity protection with local application of a barrier could be almost 100% effective in preventing post-operative adhesion formation. Future studies should confirm the efficacy of this global strategy in preventing adhesion formation after laparoscopy by focusing on clinical end points, such as reduced incidences of bowel obstruction and abdominal pain and increased fertility.
Collapse
|