Colorectal surgery: the risk and burden of adhesion-related complications

Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer

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.

Efficacy and safety of purified starch for adhesion prevention in colorectal surgery

Background

Adhesions within the abdominal cavity develop in as many as 90 % of individuals following abdominal surgery. However, the true adhesive condition of patients can only be ascertained during the second surgery.

Methods

We conducted a prospective, non-randomized study to assess the anti-adhesion properties of purified starch in patients who had undergone colorectal surgery in the past and then needed a subsequent surgical intervention. Adhesion scores have been prospectively recorded in operation notes since January 2020 when patients underwent a second surgery. Patients who had received purified starch during their initial surgery constituted the purified starch group, while those who had not received anti-adhesion medical materials were the control group. The main objectives of the study were to evaluate the extent and severity of adhesions as primary outcomes, while secondary outcomes included measuring blood loss, operation time, and postoperative complications.

Results

We analyzed the data of 101 patients, with 61 in the purified starch group and 40 in the control group. In multivariate analysis, adhesion severity (Odds ratio, 0.20, 95 % confidence interval 0.08-0.54, P < 0.01) and adhesion area scores (Odds ratio, 0.13, 95 % confidence interval 0.04-0.45, P < 0.01) were significantly lower in the purified starch group than in the control group. There was no significant difference in operation times, blood loss, and postoperative complications between the two groups.

Conclusion

Purified starch is a safe and effective anti-adhesion material that can significantly reduce the severity and extent of adhesion after colorectal surgery.

Adhesion-related readmissions after open and laparoscopic colorectal surgery in 16 524 patients

AIM

Colorectal surgery is associated with a high risk of adhesion formation and subsequent complications. Laparoscopic colorectal surgery reduces adhesion formation by 50%; however, the effect on adhesion-related complications is still unknown. This study aims to compare differences in incidence rates of adhesion-related readmissions after laparoscopic and open colorectal surgery.

METHOD

Population data from the Scottish National Health Service were used to identify patients who underwent colorectal surgery between June 2009 and June 2011. Readmissions were registered until December 2017 and categorized as being either directly or possibly related to adhesions, or as reoperations potentially complicated by adhesions. The primary outcome measure was the difference in incidence of directly adhesion-related readmissions between the open and laparoscopic cohort.

RESULTS

Colorectal surgery was performed in 16 524 patients; 4455 (27%) underwent laparoscopic surgery. Patients undergoing laparoscopic surgery were readmitted less frequently for directly adhesion-related complications, 2.4% (95% CI 2.0%-2.8%) versus 7.5% (95% CI 7.1%-7.9%) in the open cohort. Readmissions for possibly adhesion-related complications were less frequent in the laparoscopic cohort, 16.8% (95% CI 15.6%-18.0%) versus 21.7% (95% CI 20.9%-22.5%), as well as reoperations potentially complicated by adhesions, 9.7% (95% CI 8.9%-10.5%) versus 16.9% (95% CI 16.3%-17.5%).

CONCLUSION

Overall, any adhesion-related readmissions occurred in over one in three patients after open colorectal surgery and one in four after laparoscopic colorectal surgery. Compared with open surgery, incidence rates of adhesion-related complications decrease but remain substantial after laparoscopic surgery.

Post-Operative Adhesions: A Comprehensive Review of Mechanisms

Post-surgical adhesions are common in almost all surgical areas and are associated with significant rates of morbidity, mortality, and increased healthcare costs, especially when a patient requires repeat operative interventions. Many groups have studied the mechanisms driving post-surgical adhesion formation. Despite continued advancements, we are yet to identify a prevailing mechanism. It is highly likely that post-operative adhesions have a multifactorial etiology. This complex pathophysiology, coupled with our incomplete understanding of the underlying pathways, has resulted in therapeutic options that have failed to demonstrate safety and efficacy on a consistent basis. The translation of findings from basic and preclinical research into robust clinical trials has also remained elusive. Herein, we present and contextualize the latest findings surrounding mechanisms that have been implicated in post-surgical adhesion formation.

Neutrophil and monocyte kinetics play critical roles in mouse peritoneal adhesion formation

Peritoneal adhesions are pathological fibroses that ensnare organs after abdominal surgery. This dense connective tissue can cause small bowel obstruction, female infertility, and chronic abdominal pain. The pathogenesis of adhesions is a fibrotic response to tissue damage coordinated between mesothelial cells, fibroblasts, and immune cells. We have previously demonstrated that peritoneal adhesions are a consequence of mechanical injury to the mesothelial layer sustained during surgery. Neutrophils are among the first leukocytes involved in the early response to tissue damage. Here, we show that when subjected to mechanical stress, activated mesothelial cells directly recruit neutrophils and monocytes through upregulation of chemokines such as CXCL1 and monocyte chemoattractant protein 1 (MCP-1). We find that neutrophils within the adhesion sites undergo cell death and form neutrophil extracellular traps (NETosis) that contribute to pathogenesis. Conversely, tissue-resident macrophages were profoundly depleted throughout the disease time course. We show that this is distinct from traditional inflammatory kinetics such as after sham surgery or chemically induced peritonitis, and suggest that adhesions result from a primary difference in inflammatory kinetics. We find that transient depletion of circulating neutrophils significantly decreases adhesion burden, and further recruitment of monocytes with thioglycolate or MCP-1 also improves outcomes. Our findings suggest that the combination of neutrophil depletion and monocyte recruitment is sufficient to prevent adhesion formation, thus providing insight for potential clinical interventions.

Post-surgical adhesions are triggered by calcium-dependent membrane bridges between mesothelial surfaces

Surgical adhesions are bands of scar tissues that abnormally conjoin organ surfaces. Adhesions are a major cause of post-operative and dialysis-related complications, yet their patho-mechanism remains elusive, and prevention agents in clinical trials have thus far failed to achieve efficacy. Here, we uncover the adhesion initiation mechanism by coating beads with human mesothelial cells that normally line organ surfaces, and viewing them under adhesion stimuli. We document expansive membrane protrusions from mesothelia that tether beads with massive accompanying adherence forces. Membrane protrusions precede matrix deposition, and can transmit adhesion stimuli to healthy surfaces. We identify cytoskeletal effectors and calcium signaling as molecular triggers that initiate surgical adhesions. A single, localized dose targeting these early germinal events completely prevented adhesions in a preclinical mouse model, and in human assays. Our findings classifies the adhesion pathology as originating from mesothelial membrane bridges and offer a radically new therapeutic approach to treat adhesions.

Surgical adhesions are organ-joining bands of scar tissue that remain clinically untreatable. Here, the authors show that adhesions are formed through expansive mesothelial membrane bridges, and that blocking these with small molecules prevents formation of adhesions in mice.

A novel coenzyme-Q approach for the prevention of postsurgical adhesion

Objectives

Postoperative intraperitoneal adhesions are an unsolved and important problem in abdominal surgery. In the present study, the probable preventive role of coenzyme-Q in the development of peritoneal adhesions was investigated.

Material and Methods

Sixteen Wistar Hannover male rats weighing 300-350 g were randomly separated into two groups of 8 rats each. The cecum was abraded with a sterile gauze until sub-serosal hemorrhage developed. A patch of peritoneum located opposite to the cecal abrasion was completely dissected. No treatment was given to Group 1. Group 2 received 30 mg/kg coenzyme-Q, which was injected 2 mL intraperitoneally. All the rats were sacrificed on the postoperative 21^st day, and after adhesions were scored macroscopically, tissue specimens of the peritoneum and bowel were subjected to histopathological investigation. Tissue and blood specimens were also taken for biochemical analysis to investigate antioxidant efficiency.

Results

Adhesion scores were significantly different between the control group and the coenzyme-Q group (p= 0.001). According to the tissue levels of GSH-Px, MDA, and SOD levels, there was no significant difference between the study groups (p= 0.074, p= 0.208, p= 0.526). According to the plasma GSH-Px and SOD levels, there was significant difference between the groups (p= 0.002, p= 0.001), but the difference was not significant at MDA levels (p= 0.793). The differences between the pathological scores of the control and coenzyme-Q (p= 0.028 for fibrosis; p= 0.025 for inflammation) groups were statistically significant.

Conclusion

This study confirms that coenzyme-Q is the potential application in the prevention of early postoperative adhesions.

Clinical adhesion score (CLAS): development of a novel clinical score for adhesion-related complications in abdominal and pelvic surgery

Background

Adhesions are a major cause of long-term postsurgical complications in abdominal and pelvic surgery. Existing adhesion scores primarily measure morphological characteristics of adhesions that do not necessarily correlate with morbidity. The aim of this study was to develop a clinical adhesion score (CLAS) measuring overall clinical morbidity of adhesion-related complications in abdominal and pelvic surgery.

Methods

An international Delphi study was performed to identify relevant score items for adhesion-related complications, including small bowel obstruction, female infertility, chronic abdominal or pelvic pain, and difficulties at reoperation. The CLAS includes clinical outcomes, related to morbidity of adhesions, and weight factors, to correct the outcome scores for the likelihood that symptoms are truly caused by adhesions. In a pilot study, two independent researchers retrospectively scored the CLAS in 51 patients to evaluate inter-observer reliability, by calculating the Intraclass correlation coefficient. During a feasibility assessment, we evaluated whether the CLAS completely covered different clinical scenarios of adhesion-related morbidity.

Results

Three Delphi rounds were performed. 43 experts agreed to participate, 38(88%) completed the first round, and 32 (74%) the third round. Consensus was reached on 83.4% of items. Inter-observer reliability for the CLAS was 0.95 (95% CI 0.91–0.97). During feasibility assessment, six items were included. As a result, the CLAS includes 22 outcomes and 23 weight factors.

Conclusion

The CLAS represents a promising scoring system to measure and monitor the clinical morbidity of adhesion-related complications. Further studies are needed to confirm its utility in clinical practice.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07621-5) contains supplementary material, which is available to authorized users.

Cost-effectiveness of the prevention of adhesions and adhesive small bowel obstruction after colorectal surgery with adhesion barriers: a modelling study

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.

Surgical adhesions in mice are derived from mesothelial cells and can be targeted by antibodies against mesothelial markers

Peritoneal adhesions are fibrous tissues that tether organs to one another or to the peritoneal wall and are a major cause of postsurgical and infectious morbidity. The primary molecular chain of events leading to the initiation of adhesions has been elusive, chiefly due to the lack of an identifiable cell of origin. Using clonal analysis and lineage tracing, we have identified injured surface mesothelium expressing podoplanin (PDPN) and mesothelin (MSLN) as a primary instigator of peritoneal adhesions after surgery in mice. We demonstrate that an anti-MSLN antibody diminished adhesion formation in a mouse model where adhesions were induced by surgical ligation to form ischemic buttons and subsequent surgical abrasion of the peritoneum. RNA sequencing and bioinformatics analyses of mouse mesothelial cells from injured mesothelium revealed aspects of the pathological mechanism of adhesion development and yielded several potential regulators of this process. Specifically, we show that PDPN+MSLN+ mesothelium responded to hypoxia by early up-regulation of hypoxia-inducible factor 1 alpha (HIF1α) that preceded adhesion development. Inhibition of HIF1α with small molecules ameliorated the injury program in damaged mesothelium and was sufficient to diminish adhesion severity in a mouse model. Analyses of human adhesion tissue suggested that similar surface markers and signaling pathways may contribute to surgical adhesions in human patients.

Impact of postcolectomy adhesion-related complications on healthcare utilization

Objective

The objective of this study was to explore adhesion-related complications (ARCs) within 1 year after colectomy.

Methods

Using Truven MarketScan® Commercial and Medicare databases, the first inpatient colectomies during 2009–2013 (index) were identified: left, right, partial, transverse, or total. One-year continuous enrollment was required pre and postindex. Only the first inpatient rehospitalization event was analyzed. ARC was defined as the subset of rehospitalizations with a diagnosis of ileus, small bowel obstruction, or postindex adhesiolysis. ARC and non-ARC events were evaluated descriptively, including time to ARC, length of stay (LOS), and total hospitalization reimbursement (2015 US dollars [2015 USD]). Patient, provider, and procedure factors associated with ARC were explored using logistic regression models.

Results

A total of 64,532 colectomies were identified: left (39.2%), right (34.9%), partial (20.0%), transverse (2.3%), and total (3.6%). Surgical approach was classified as open (60.1%) and laparoscopic (39.9%). All-cause first inpatient readmission incidence within 1 year was 24.7%, and ARC incidence was 5.7% in all patients or 23.2% in all first readmissions. ARC had statistically higher resource utilization compared to non-ARC with respective mean (SD) time to event (130 [102] and 137 [106] days), mean (SD) LOS (7.2 [8.0] and 5.2 [6.8] days), and mean (SD) total reimbursement ($29,802 [$43,037] and $22,476 [$36,130]). ARC risk factors included (OR [95% CI]) resection type (total vs right, 3.78 [3.27–4.36]), left vs right (1.69 [1.53–1.86]), adhesiolysis (2.45 [1.42–4.23]), computerized tomography (1.79 [1.65–1.95]), surgical indication: inflammatory bowel disease vs cancer (1.69 [1.43–1.99]), and multiple abdominal procedures (1.38 [1.29–1.49]). Laparoscopic approach was protective (0.42 [0.39–0.46]).

Conclusion

ARCs were associated with almost one-fourth of all first rehospitalizations within the first year after colectomy and were associated with substantial healthcare utilization. Risk factors included increased index colectomy complexity, while the laparoscopic approach was protective. Future research is needed to better identify high-risk patients and allow for appropriate economic and clinical risk adjustment of outcomes.

Patients With Adhesive Small Bowel Obstruction Should Be Primarily Managed by a Surgical Team

OBJECTIVE

To evaluate the impact of a primary medical versus surgical service on healthcare utilization and outcomes for adhesive small bowel obstruction (SBO) admissions.

SUMMARY BACKGROUND DATA

Adhesive-SBO typically requires hospital admission and is associated with high healthcare utilization and costs. Given that most patients are managed nonoperatively, many patients are admitted to medical hospitalists. However, comparisons of outcomes between primary medical and surgical services have been limited to small single-institution studies.

METHODS

Unscheduled adhesive-SBO admissions in NY State from 2002 to 2013 were identified using the Statewide Planning and Research Cooperative System. Bivariate and mixed-effects regression analyses were performed assessing factors associated with healthcare utilization and outcomes for SBO admissions.

RESULTS

Among 107,603 admissions for adhesive-SBO (78% nonoperative, 22% operative), 43% were primarily managed by a medical attending and 57% were managed by a surgical attending. After controlling for patient, physician, and hospital-level factors, management by a medical service was independently associated with longer length of stay [IRR = 1.39, 95% confidence interval (CI) = 1.24, 1.56], greater inpatient costs (IRR = 1.38, 95% = 1.21, 1.57), and a higher rate of 30-day readmission (OR = 1.32, 95% CI = 1.22, 1.42) following nonoperative management. Similarly, of those managed operatively, management by a medicine service was associated with a delay in time to surgical intervention (IRR = 1.84, 95% CI = 1.69, 2.01), extended length of stay (IRR=1.36, 95% CI = 1.25, 1.49), greater inpatient costs (IRR = 1.38, 95% CI = 1.11, 1.71), and higher rates of 30-day mortality (OR = 1.92, 95% CI = 1.50, 2.47) and 30-day readmission (OR = 1.13, 95% CI = 0.97, 1.32).

CONCLUSIONS

This study suggests that management of patients presenting with adhesive-SBO by a primary medical team is associated with higher healthcare utilization and worse perioperative outcomes. Policies favoring primary management by a surgical service may improve outcomes and reduce costs for patients admitted with adhesive-SBO.

Prevention of Intraabdominal Adhesions: An Experimental Study Using Mitomycin-C and 4% Icodextrin

Background:

Intraabdominal adhesions remain a significant cause of morbidity and mortality. Moreover, intraabdominal adhesions can develop in more than 50% of abdominal operations.

Aims:

We compared the anti-adhesive effects of two different agents on postoperative adhesion formation in a cecal abrasion model.

Study Design:

Experimental animal study.

Methods:

Forty Wistar albino type female rats were anesthetized and underwent laparotomy. Study groups comprised Sham, Control, Mitomycin-C, 4% Icodextrin, and Mitomycin-C +4% Icodextrin groups. Macroscopic and histopathological evaluations of adhesions were performed.

Results:

The frequencies of moderate and severe adhesions were significantly higher in the control group than the other groups. The mitomycin-C and Mitomycin-C +4% Icodextrin groups were associated with significantly lower adhesion scores compared to the control group and 4% Icodextrin group scores (p=0.002 and p=0.008, respectively). The adhesion scores of the Mitomycin-C group were also significantly lower than those of the 4% Icodextrin group (p=0.008).

Conclusion:

Despite its potential for bone marrow toxicity, Mitomycin-C seems to effectively prevent adhesions. Further studies that prove an acceptable safety profile relating to this promising anti-adhesive agent are required before moving into clinical trials.

The effect of oral simvastatin on fibrinolytic activity after colorectal surgery-a pilot study

BACKGROUND

Studies conducted in animal models have shown that statins (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors) reduce adhesion formation by upregulating fibrinolysis. The aim of this study was to determine the effect of orally administered statins on the promoters and inhibitors of the fibrinolytic pathway.

METHODS

In a previously described double-blinded clinical trial, 144 patients undergoing elective colorectal resection, or reversal of Hartmann's procedure were randomized to receive 40 mg once daily oral simvastatin 3-7 d before surgery or placebo. For the purposes of the present study, peritoneal drain fluid was collected postoperatively from patients to measure active tissue plasminogen activator (tPA), tissue plasminogen activator total antigen, active plasminogen activator inhibitor-1 (PAI-1), plasminogen activator inhibitor total antigen (PAI-1TA), plasminogen activator inhibitor-1 and tissue plasminogen activator complex (PAI-1/tPA). These were analyzed using ELISA. The number of hospitalizations and complications related to small bowel obstruction (SBO) were recorded at 2 y after surgery.

RESULTS

A total of 95 patients (72%) had sufficient peritoneal drain fluid suitable for ELISA analysis. Of them, 46 patients (48%) were from the oral simvastatin group. Mean tPA and tPA total antigen concentrations in peritoneal fluid were similar between the two groups. Mean PAI-1 and PAI-1 TA concentrations in the statin and placebo group were also similar. Mean PAI-1/tPA complex concentration was similar between the two groups. The number of hospitalizations from SBOs were 5 and 4 in the statin and placebo groups respectively (P = 0.46). The overall mortality at 2-year post-surgery was similar between the two groups (P = 0.59).

CONCLUSIONS

In this pilot study involving humans, oral simvastatin had no measured effect on the peritoneal fibrinolytic pathway in the first 24 h after colorectal surgery. Analysis of clinical outcomes also showed that oral simvastatin did not reduce hospitalizations for SBO in the 2 y after surgery. Further studies may be useful to evaluate whether fibrinolytic pathways beyond 24 h are altered after systemic administration of statins and to evaluate the use of higher doses of statins, perhaps used intraperitoneally rather than systemically.

Effect of Pirfenidone on Vascular Proliferation, Inflammation and Fibrosis in an Abdominal Adhesion Rat Model

AIM

To study the efficacy of pirfenidone for prevention of postoperative adhesion formation in an adhesion rat model.

MATERIALS AND METHODS

Eighteen female Wistar rats were subjected to right-sided parietal peritoneum and right uterine horn adhesion model. Rats were randomized into three groups: group 1 (control) (closure of midline abdominal incision without any agent administration), group 2 (closure of incision after intraperitoneal administration of pirfenidone), and group 3 (closure of incision and only oral administration of pirfenidone for 14 days). Relaparotomy was performed 14 days after the first surgery. Effect of pirfenidone on adhesion formation was assessed on light microscopy by scoring vascular proliferation, inflammation, fibrosis, and collagen formation in the scarred tissue. Effect of pirfenidone on inflammation was assessed by measurement of transforming growth factor-β and interleukin-17 levels in scarred tissue.

RESULTS

The degree of vascular proliferation (1.32 ± 0.39 versus 2.34 ± 0.46, p < 0.001), inflammation (1.60 ± 0.70 versus 2.60 ± 0.52, p < 0.01), and fibrosis (1.50 ± 0.53 versus 2.40 ± 0.52, p < 0.01) were less prominent in group 2 compared to group 1, respectively. Only vascular proliferation was found to be less prominent in group 3 compared to group 1 (1.60 ± 0.42 versus 2.34 ± 0.46, p < 0.01). Intraperitoneal and oral administration of pirfenidone reduced tissue levels of inflammatory markers (TGF-β and IL-17) in parietal and visceral peritoneum compared to control group. Intraperitoneal administration of pirfenidone compared to oral administration was more effective in reducing tissue levels of inflammatory markers.

CONCLUSION

Pirfenidone is an effective agent on the prevention of postoperative vascular proliferation, inflammation and fibrosis in scarred tissue particularly with intraperitoneal administration.

Adhesive small bowel obstruction after laparoscopic and open colorectal surgery: a systematic review and meta-analysis

BACKGROUND

It is considered that laparoscopic surgery is associated with a much lower rate of postoperative formation of adhesions than open surgery. This meta-analysis assessed the incidence of adhesion-related readmissions and surgery for adhesive small bowel obstruction (SBO) in patients who underwent laparoscopic or open colorectal surgery.

METHODS

Multiple comprehensive databases were searched systematically to identify relevant studies and meta-analysis was done.

RESULTS

Meta-analysis showed that laparoscopic surgery was associated with a lower rate of adhesive SBO, both for randomized clinical trials (relative risk [RR] .26, 95% confidence interval [CI] .10 to .67, I(2)=41%) and nonrandomized studies (RR .49, 95% CI .32 to .76, I(2)=91%). Laparoscopic surgery was also associated with a lower rate of subsequent surgery for adhesive SBO, both for randomized clinical trials (RR .25, 95% CI .06 to .96, I(2)=0%) and nonrandomized studies (RR .56, 95% CI .33 to .94, I(2)=77%).

CONCLUSIONS

Laparoscopic colorectal surgery significantly reduced the rates of adhesive SBO and subsequent surgery for adhesive SBO, compared with open surgery.

Use of Modified Polysaccharide 4DryField (®) PH for Adhesion Prevention and Hemostasis in Gynecological Surgery: A Two-Center Observational Study by Second-Look Laparoscopy

Purpose. This study evaluates both scopes of 4DryField PH, certified for adhesion prevention and hemostasis, in patients undergoing surgery for various and severe gynecological disorders. Methods. This is a two-institutional study. Adhesion prevention efficacy was evaluated using video documentation of first-look laparoscopies (FLL) and second-look laparoscopies (SLL); other patient data were analyzed retrospectively. Twenty patients with various disorders were evaluated, 4 assigned to a uterus pathology, 10 to endometriosis, and 6 to an adhesion disease group. Nine patients received 4DryField primarily for hemostasis and 11 solely for adhesion prevention. Nineteen patients had SLL after 5 to 12 weeks and one after 13 months. Results. At FLL with 4DryField, immediate hemostasis could be achieved in diffuse bleeding. At SLL, effective adhesion prevention was observed in 18 of all 20 women, with only 2 revealing major adhesions. In particular, only 1 of the 6 women with adhesion disease as predominant disorder showed major adhesions at SLL. Conclusions. Modified polysaccharide 4DryField is not only effective in diffuse bleeding. In this cohort with extensive surgery for various gynecological pathologies, 4DryField showed effective adhesion prevention as confirmed at SLL, too. Its use as premixed gel is a convenient variant for treatment of large peritoneal wounds.

Safety and Efficacy of Sodium Hyaluronate Gel and Chitosan in Preventing Postoperative Peristomal Adhesions After Defunctioning Enterostomy: A Prospective Randomized Controlled Trials

Peristomal adhesions complicate closure of defunctioning enterostomy. The efficacy and safety of sodium hyaluronate gel and chitosan in preventing postoperative adhesion have not been extensively studied. This study aims to evaluate the safety and efficacy of sodium hyaluronate gel and chitosan in the prevention of postoperative peristomal adhesions.This was a prospective randomized controlled study. One hundred and fourteen patients undergoing defunctioning enterostomy were enrolled. Patients were randomly assigned to receive sodium hyaluronate gel (SHG group) or chitosan (CH group) or no antiadhesion treatment (CON group) during defunctioning enterostomy. The safety outcomes included toxicities, stoma-related complications, and short-term and long-term postoperative complications. Eighty-seven (76.3%) of the 114 patients received closure of enterostomy, during which occurrence and severity of intra-abdominal adhesions were visually assessed by a blinded assessor.Incidence of adhesion appears to be lower in patients received sodium hyaluronate gel or chitosan but differences did not reach a significant level (SHG group vs CH group vs CON group: 62.1% vs 62.1% vs 82.8%, P = 0.15). Compared with the CON group, severity of postoperative adhesion was significantly decreased in the SHG and CH group (SHG group vs CH group vs CON group: 31.0% vs 27.6% vs 62.1%; P = 0.01). There was no significant difference in the occurrence of postoperative complications and other safety outcomes among the 3 groups.Sodium hyaluronate gel or chitosan smeared around the limbs of a defunctioning enterostomy was safe and effective in the prevention of postoperative peristomal adhesions.

Predicting formation of adhesions after gynaecological surgery: development of a risk score

PURPOSE

Risk factors for post-surgical adhesions following gynaecological surgery have been identified, but their relative importance has not been precisely determined. No practical tool exists to help gynaecological surgeons evaluate the risk of adhesions in their patients. The purpose of the study was to develop an Adhesion Risk Score to provide a simple tool that will enable gynaecological surgeons to routinely quantify the risk of post-surgical adhesions in individual patients.

METHODS

A group of European gynaecological surgeons searched the literature to identify the risk factors and the surgical operations reported as carrying a risk of post-surgical adhesions. Through consensus process of meetings and communication, a four-point scale was then used by each surgeon to attribute a specific weight to each item and collective agreement reached on identified risk factors and their relative importance to allow construct of a useable risk score.

RESULTS

Ten preoperative and 10 intraoperative risk factors were identified and weighed, leading to the creation of two sub-scores to identify women at risk prior to and during surgery. The Preoperative Risk Score can range from 0 to 36, and the Intraoperative Risk Score from 3 to 31. Several thresholds between these limits may be used to identify women with low, medium, and high risk of post-surgical adhesions.

CONCLUSIONS

Gynaecological surgeons are encouraged to use this Adhesion Risk Score to identify the risk of adhesions in their patients. This will allow better informed use of available resources to target preventive measures in women at high risk of post-surgical adhesions.

Early postoperative small bowel obstruction is an independent risk factor for subsequent adhesive small bowel obstruction in patients undergoing open colectomy

BACKGROUND

This prospective study was performed to investigate whether postoperative ileus (POI) or early postoperative small bowel obstruction (EPSBO) affects the development of adhesive small bowel obstruction (SBO) in patients undergoing colectomy.

METHODS

We prospectively enrolled 1,002 patients who underwent open colectomy by a single surgeon. POI was defined as the absence of bowel function for more than 5 days or as a delay in oral intake beyond 7 days postoperatively. EPSBO was defined as the clinical and radiologic identification of SBO after resuming oral intake between postoperative days 7 and 30. Adhesive SBO was defined as SBO developing after 30 days because of intraperitoneal adhesion. The associations between POI, EPSBO, patient- and surgery-related variables, and the development of adhesive SBO were analyzed.

RESULTS

A total of 85 (8.5 %) patients developed POI, and 42 patients (4.2 %) developed EPSBO, with seven patients experiencing both POI and EPSBO. During the follow-up period (median 51 months), 70 patients (7.0 %) developed adhesive SBO, six (8.6 %) of whom needed laparotomy. The occurrence of adhesive SBO was significantly higher in patients with EPSBO than in those without EPSBO (26.5 vs. 7.5 % at 5 years, P < 0.001), but not in patients with POI (13.4 vs. 7.8 % at 5 years, P = 0.158). Multivariable analysis showed colostomy (hazard ratio [HR] 2.530, P = 0.006) and EPSBO (HR 4.063, P < 0.001) as independent risk factors for adhesive SBO.

CONCLUSIONS

The development of adhesive SBO after colectomy is more frequent in patients with EPSBO and colostomy; however, POI does not increase the risk of adhesive SBO.

Effect of Hypericum perforatum on intraperitoneal adhesion formation in rats

INTRODUCTION

The aim of this study was to evaluate the efficacy of Hypericum perforatum for prevention of adhesion formation in rats.

MATERIAL AND METHODS

Twenty-four female wistar rats underwent left uterine horn adhesion model. Rats were randomised into 4 groups. Group 1 (Control): Closure of abdominal incision without any agent administration. Group 2: Closure of incision after administration of intraperitoneal (i.p.) Ringer's lactate solution. Group 3: Closure of incision after administration of i.p. olive oil (diluent of H. perforatum). Group 4: Hypericum perforatum extract (Ecodab(®)) was administered i.p. before the closure of incision. Fourteen days later, relaparatomy was performed and surgical adhesion scores, inflammation and fibrosis scores were noted. Groups were compared according to these scores.

RESULTS

There was statistical significant difference between ringer's lactate group and olive oil group according to surgical adhesion score (p = 0.009). However, groups were not different according to inflammation and fibrosis scores (p > 0.05).

CONCLUSIONS

Despite antiinflammatory, antioxidants and antimicrobial properties of H. perforatum, our results revealed no positive effect of H. perforatum on the prevention of intraperitoneal adhesion formation.

Antiadhesive effect and safety of sodium hyaluronate-carboxymethyl cellulose membrane in thyroid surgery

Purpose

A number of researchers have suggested the use of sodium hyaluronate carboxymethyl cellulose (HA-CMC) membrane for preventing postoperative adhesion. This study evaluated the antiadhesive effect and safety of HA-CMC membrane in thyroidectomy for papillary thyroid cancer.

Methods

One hundred sixty-two patients who underwent thyroidectomy were prospectively randomized. In the study group of 80 patients, the 7.5 cm × 13 cm HA-CMC membrane was applied to the operative field after thyroidectomy. The subjects were asked about complications including adhesive symptoms using an 8-item questionnaire at 2 weeks, 3 months, and 6 months after surgery. In addition, items on the appearance of neck wrinkles and scars were evaluated by a physician who had no information about the patient's allocation.

Results

There were no significant differences in complications such as swallowing difficulty, and wrinkles between study and control groups. Both groups presented significantly decreased scores over time in swallowing difficulty, and wrinkles. There were no complications regarding the HA-CMC membrane.

Conclusion

The antiadhesive effect of HA-CMC membrane in thyroid surgery is still uncertain, although it is biologically safe. Further investigation is needed to confirm the antiadhesive effect of HA-CMC membrane in thyroid surgery.

Record linkage in Scotland and its applications to health research

AIMS AND OBJECTIVES

  This paper will focus on the key concepts behind record linkage and describe how probability matching of Scottish health records can be used for national health research.

BACKGROUND

  Record linkage can bring together two or more records relating to the same individual. This allows information from multiple sources to be joined together to produce richer data sets for research purposes and has wide applicability in public health and epidemiological research. The probability matching techniques underpinning record linkage bring together records on a patient basis using key identifying information on each record. Scotland has a strong track record for performing linkage for research purposes owing to routinely collected and well-maintained national administrative health data sets, the emergence of the Scottish record linkage system and organisations like the Information Services Division of NHS National Services Scotland who centrally hold permanently linked patient-based databases. Design.  A record linkage retrospective population cohort study is described within this paper.

METHODS

  The paper will describe current linkage methodology before discussing typical applications in the setting of Information Services Division and focusing on a particular linkage study investigating rates and risk factors for gastroschisis.

RESULTS

  Conclusions from the gastroschisis study are typical of the types of important findings drawn from analysing linked health data.

CONCLUSIONS

  Scotland's good track record for linking records for health research is evidenced by the high volume of research projects, publications and findings resulting from probability matching of national health data. Relevance to clinical practice.  Record linkage allows information relating to the same person held across different data sources to be brought together. Probabilistic record linkage can overcome data quality issues, producing accurate matches. This allows linked, analysable, patient-based databases, capable of answering complex research questions, to be produced from several data sources with wide applications in the field of health research.

Minimal-access colorectal surgery is associated with fewer adhesion-related admissions than open surgery

BACKGROUND

This study aimed to describe national intermediate-term admission rates for incisional hernia or clinically apparent adhesions following colorectal surgery, and to compare rates following laparoscopic and open approaches.

METHODS

Patients undergoing primary colorectal resection between 2002 and 2008 were included from the Hospital Episode Statistics database. Subsequent inpatient admissions were extracted for up to 3 years after the initial operation or to the end of the study period. Outcomes examined were admissions with a diagnosis of, or operative interventions for, incisional hernia or adhesions.

RESULTS

A total of 187 148 patients were included between 2002 and 2008, with median follow-up of 31·8 (interquartile range 13·1-35·3) months. Some 8885 (4·7 per cent) of these patients were admitted with a diagnosis of, or underwent a repair of, an incisional hernia. In multiple regression analysis, use of laparoscopy was not a predictor of operative intervention for incisional hernia (odds ratio 1·09, 95 per cent confidence interval (c.i.) 0·99 to 1·21; P = 0·083). Some 15 125 (8·1 per cent) of the patients were admitted with a diagnosis of adhesions or had a procedure for division of adhesions. Overall, 3·5 per cent (6637 of 187 148) of patients underwent adhesiolysis. Patients selected for a laparoscopic procedure had lower rates of admission for adhesions (6·3 per cent (692 of 11 013) for laparoscopic versus 8·2 per cent (14 433 of 176 135) for open surgery; P < 0·001) and reintervention for adhesions (2·8 per cent (305 of 11 013) versus 3·6 per cent (6325 of 176 135) respectively; P < 0·001) than those undergoing an open procedure. In multiple regression analysis, patients selected for a laparoscopic procedure had lower subsequent intervention rates for adhesions (odds ratio 0·80, 95 per cent c.i. 0·71 to 0·90; P < 0·001).

DISCUSSION

Patients undergoing colorectal resection who are selected for the laparoscopic approach have a lower risk of developing clinically significant adhesions.

Secular trends in small-bowel obstruction and adhesiolysis in the United States: 1988-2007

BACKGROUND

Postoperative adhesions are common after surgery and can cause small-bowel obstruction (SBO) and require adhesiolysis. The impact that laparoscopy and other surgical advances have had on rates of SBO and adhesiolysis remains controversial. This study examines trends in discharges from US hospitals for SBO and adhesiolysis from 1988 to 2007.

METHODS

We performed an analysis of secular trends for SBO and adhesiolysis, using the National Hospital Discharge Survey. Spearman correlation coefficients were calculated to assess trends over time.

RESULTS

Rates of SBO were stable over time (ρ = .140; P = .28). Adhesiolysis rates were stable over time (ρ = -.18; P = .17), although there were significant downward trends in patients older than age 65 (ρ = -.55; P = .01) and age 15 to 44 (ρ = -.84; P < .01).

CONCLUSIONS

There has been no significant change in overall rates of SBO or adhesiolysis from 1988 to 2007. For adhesiolysis, there were decreasing trends when stratified by age. Further research is required to understand the factors associated with adhesion-related complications.

Adhesion formation to hemostatic agents and its reduction with a sodium hyaluronate/carboxymethylcellulose adhesion barrier

The impact of hemostatic agents on postoperative adhesion formation has not been well studied. We hypothesized that hemostatic agents would be a significant nidus for adhesion formation and that a resorbable barrier would effectively reduce adhesions to hemostatic agents. Four commercial hemostatic agents, each composed of a different biomaterial matrix, were implanted in female Sprague-Dawley rats, and adhesion formation was examined 7 days after surgery. In separate studies, the effects of serosal trauma (via cecal abrasion), added blood, and the presence of chemically modified sodium hyaluronate/carboxymethylcellulose (HA/CMC) barrier on adhesion formation to hemostatic agents were studied. Significant adhesions formed to hemostatic agents even in the absence of traumatized tissue. When applied after cecal abrasion, the incidence of adhesions to the hemostatic agents increased. Addition of blood to this model increased adhesion formation even further, causing adhesions in every animal in the study. An HA/CMC adhesion barrier reduced adhesions to hemostatic agents in the presence of serosal trauma and maintained effectiveness even in the presence of blood. In conclusion, hemostatic agents potentiated adhesion formation at the site of application in a model without trauma. In more challenging models, their adhesiogenic contribution was overwhelmed by trauma and blood. HA/CMC adhesion barrier applied over hemostatic agents at the time of surgery provided significant protection against postoperative adhesions in these preclinical models.

A review of the problematic adhesion prophylaxis in gynaecological surgery

Background

Adhesions lead to considerable patient morbidity and are a mounting burden on surgeons and the health care system alike. Although adhesion formation is the most frequent complication in abdominal and pelvic surgery, many surgeons are still not aware of the extent of the problem. To provide the best care for their patients, surgeons should consistently inform themselves of anti-adhesion strategies and include these methods in their daily routine.

Methods

Searches were conducted in PubMed and The Cochrane Library to identify relevant literature.

Findings

Various complications are associated with adhesion formation, including small bowel obstruction, infertility and chronic pelvic pain. Increasingly, an understanding of adhesion formation as a complex process influenced by many different factors has led to various conceivable anti-adhesion strategies. At present, a number of different anti-adhesion agents are available. Although some agents have proved effective in reducing adhesion formation in randomised controlled trials, none of them can completely prevent adhesion formation.

Conclusion

To fulfil our duty to provide best possible care for our patients, it is now time to regard adhesions as the most common complication in surgery. Further research is needed to fully understand adhesion formation and to develop new strategies for adhesion prevention. Large clinical efficacy trials of anti-adhesion agents will make it easier for surgeons to decide which agent to use in daily routine.

Bowel obstruction after laparoscopic and open colon resection for cancer: results of 5 years of follow-up in a randomized trial

BACKGROUND

Postoperative bowel obstruction caused by intra-abdominal adhesions occurs after all types of abdominal surgery. It has been suggested that the laparoscopic technique should reduce the risk for adhesion formation and thus for postoperative bowel obstruction. This study was designed to compare the incidence of bowel obstruction in a randomized trial where laparoscopic and open resection for colon cancer was compared.

METHODS

A retrospective analysis was performed, collecting data of episodes of bowel obstruction with or without surgery. Only episodes treated in the hospital where the index surgery took place were included. Data for 786 patients were collected for the 5-year period after cancer surgery.

RESULTS

Baseline characteristics for the evaluated laparoscopic (n = 383) and open (n = 403) groups were comparable. The cumulative obstruction percentages at 5 years for the open and laparoscopic groups were 6.5 and 5.1% respectively and did not significantly differ from each other. Tumor stage seemed to influence the risk for bowel obstruction: 2.8% in stage I, 6.6% in stage II, and 7% in stage III, but the differences were not significant.

CONCLUSIONS

This analysis does not support the hypothesis that laparoscopy leads to fewer episodes of bowel obstruction compared with open surgery.

Factors affecting insertion time for colonoscopy performed under intramuscular analgesia in patients with history of colorectal resection

BACKGROUND

Colonoscopy can detect both early intraluminal recurrence and metachronous neoplasia after colorectal cancer resection. Because colon length and location change after colorectal resection, factors affecting insertion time during colonoscopy also might be altered. The goal of this study was to examine whether colonoscope insertion time differs between left-sided resection and right-sided resection and to identify factors that impact the performance of colonoscopy after colorectal resection.

METHODS

We included consecutive patients who underwent colonoscopy between November 2005 and November 2009 after colorectal resection for colorectal cancer. We classified surgical methods into left-sided resection (left hemicolectomy, low anterior resection, anterior resection, Hartman, and Mile's operation) or right-sided resection (right hemicolectomy) and retrospectively evaluated the colonoscope insertion time. Moreover, we analyzed factors that might affect the insertion time.

RESULTS

A total of 1,260 patients underwent colonoscopy after colorectal resection during the study period. Of these, 1,248 patients (771 men) who underwent complete colonoscopy were evaluated in this study. The colonoscopy completion rate was 99%, and the mean insertion time was 6.5±5.1 min (median, 5 min; range, 0.3-61 min). Right-sided resection, female gender, poor quality of bowel preparation, lower endoscopist case volume, open laparotomy, and colonoscopy performed more than 1 year after colorectal resection were found to be independent factors associated with prolonged insertion time.

CONCLUSIONS

This large study identified six factors that affect colonoscope insertion time after colorectal resection. These findings have implications for the practice and teaching of colonoscopy after colorectal resection.

Prevention of postoperative peritoneal adhesions: a review of the literature

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.

The incidence and risk factors of post-laparotomy adhesive small bowel obstruction

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.

Implications of late complications from adhesions for preoperative informed consent

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.

Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial

BACKGROUND

This study investigated adhesive intestinal obstruction (AIO) and incisional hernia (IH) in patients undergoing laparoscopically assisted and open surgery for colorectal cancer.

METHODS

In a case-note review of patients randomized to the Medical Research Council's Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) trial, primary and key secondary endpoints were AIO and IH admission rates respectively.

RESULTS

Of 411 patients, 11 were admitted for AIO: four (3.1 per cent) of 131 patients in the open arm of the trial versus seven (2.5 per cent) of 280 in the laparoscopic arm (difference 0.6 (95 per cent confidence interval (c.i.) - 2.9 to 4.0) per cent). Thirty-six patients developed IH: 12 (9.2 per cent) after open versus 24 (8.6 per cent) after laparoscopic surgery (difference 0.6 (95 per cent c.i. - 5.3 to 6.5) per cent). Results by actual procedure showed higher AIO and IH rates in the 24.5 per cent of patients who converted from laparoscopic to open surgery (AIO: 2.3, 2.0 and 6 per cent; IH: 8.6, 7.4 and 11 per cent-for open, laparoscopic and converted operations respectively).

CONCLUSION

Although this study has not confirmed that laparoscopic surgery reduces rates of AIO and IH after colorectal cancer surgery, trends suggest that a reduction in conversion to open surgery and elimination of port-site hernias may produce such an effect. Registration number for CLASICC trial: ISRCTN74883561 (http://www.controlled-trials.com).

The effect of 4% icodextrin solution on adhesiolysis surgery time at the Hartmann's reversal: a pilot, multicentre, randomized control trial vs lactated Ringer's solution

OBJECTIVE

A pilot randomized controlled clinical multicentre trail was established to compare intraperitoneal 4% icodextrin (ID) solution with lactated Ringer's solution (LRS) on adhesion formation after Hartmann's procedure. The adhesiolysis surgery time during Hartman's reversal was used as a marker of the severity of adhesions.

METHOD

Patients scheduled for Hartmann's resection were randomized at surgery to either of the two study solutions used as an irrigant during the operation and instilled (1000 ml) at the end of surgery. During the reversal procedure, the time for small bowel adhesiolysis was recorded.

RESULTS

On completion of 17 eligible patients, an interim analysis was performed. There were no complications following the use of 4% ID solution. The mean (SD) total adhesiolysis times in patients treated with 4% ID solution and LRS were 30.8 (18.0) min and 47.6 (45.7) min, respectively. The mean reduction of 16.8 min, although greater than expected, was not statistically significant (P = 0.33) because of the large variance in adhesiolysis times. Further statistical analysis showed that to achieve significance for the observed differences and variance, a minimum of 240 patients in each group would be required.

CONCLUSION

Icodextrin treatment resulted in a decreasing trend in adhesiolysis time. The use of 4% ID solution in peritonitis patients seemed to be safe. Because of larger than expected variations in adhesiolysis times, this pilot study was underpowered to meet the study end-point and further statistical modelling estimated that significance cannot be reached within a reasonable time scale. Other models should be used to evaluate the efficacy of anti-adhesive agents.

Does prior abdominal surgery influence conversion rates and outcomes of laparoscopic right colectomy in patients with neoplasia?

PURPOSE

The study investigated the impact of prior abdominal surgery on conversions and outcomes of laparoscopic right colectomy.

METHODS

A consecutive series of 414 patients with cancer or adenomas who underwent a laparoscopic right colectomy from March 1996 to November 2006 were studied for surgical conversions and outcomes. Conversion was defined as an incision length > 7 cm.

RESULTS

Patients with prior abdominal surgery (n = 191) were compared with patients with no prior abdominal surgery (n = 223), and showed no significant differences in age, ASA classification, length of stay, operative time, blood loss, harvested nodes, tumor size, and specimen length. Significantly more wound infections occurred in the prior abdominal surgery group (22 vs.12, P = 0.023). Body mass index > 30 showed a three-fold increased risk of conversion. Fifteen percent of the no prior abdominal surgery patients and 17 percent of the prior abdominal surgery patients were converted (P > 0.05). Conversion was associated with a longer mean length of stay (8.8 days) relative to laparoscopically completed cases (6.3 days) regardless of prior abdominal surgery history (P < 0.0001).

CONCLUSIONS

Laparoscopic right colectomy for neoplasia was not associated with a higher conversion rate or morbidity in patients with prior abdominal surgery. Prior abdominal surgery is not a contraindication to laparoscopic right colectomy.

Prevention of intra-abdominal adhesions in gynaecological surgery

Important progress has been made in the field of post-surgical adhesion prevention with the development of consensus statements in gynaecology from the United Kingdom, Germany, the European Society of Gynaecological Endoscopy, Call for Action in Colorectal Surgery and a recent Technical Bulletin from The Practice Committee of the American Society of Reproductive Medicine. These reports suggest that the application of adhesion reduction devices together with the use of microsurgical principles reduces the formation of post-operative adhesions. This commentary provides additional information to assist gynaecologists in making surgical decisions. However, variation in adhesion classifications, mode of device application, lack of uniformity in surgical approaches and variations in interpretation of results make comparative assessment of the efficacy of adhesion reduction devices and surgical techniques difficult. Considering the choice of an adhesion-reduction device, one has to evaluate the cost and its clinical impact carefully. This is particularly important if one were to support routine, prophylactic use of adhesion-reduction devices. Healthcare providers should take into account the needs of individual patients, available resources, and institutional or clinical practice limitations. Good surgical technique and perhaps the use of approved devices for adhesion reduction would give patients the best chance to benefit from reproductive and gynaecological surgery.

What is the Rate of Small Bowel Obstruction after Colectomy?

The rate of small bowel obstruction (SBO) after colectomy is unknown. Given the large number of colectomies performed in the United States, elucidating SBO rates, outcomes, and identifying predictors of readmission is important. Using the California Inpatient File, we identified all patients readmitted with a principle diagnosis of SBO at least once in the 3 years after colectomy (n = 4555). Patients admitted with a diagnosis of SBO in the 3 years before surgery were excluded. Overall, 10 per cent of patients were readmitted for SBO at least once after colectomy. Approximately 58 per cent were readmitted in the first year and 22 per cent of these patients required surgery. The most common operation performed was lysis of adhesions. Median length of stay was twice as long in the surgery group versus the no surgery group (12 vs 6 days). Overall mortality was higher in the nonsurgery group compared with the surgery group (33% vs 21%, P < 0.001) and highest in the elderly (44% vs 30%, P < 0.001). One in 10 patients without a history of SBO who undergoes a colectomy will be readmitted at least once in the subsequent 3 years for SBO, and there is a high mortality rate in this group, especially in the elderly.

Reduced adhesion formation following laparoscopic versus open colorectal surgery

BACKGROUND

Adhesion formation is common after abdominal surgery. This study aimed to compare the extent of adhesion formation following laparoscopic and open colorectal surgery.

METHODS

An observational study was undertaken to identify adhesions in patients undergoing laparoscopy after previous laparoscopic or open colectomy. Adhesions were scored according to a system validated for interobserver (median kappa = 0.80) and intraobserver (kappa = 0.82) agreement. The primary endpoint was the overall adhesion score (0-10); a secondary endpoint was the adhesion score at the main incision site (0-6).

RESULTS

Forty-six patients were recruited (13 laparoscopic and 33 open colectomy). In most patients (n = 29), laparoscopy was performed for tumour staging before liver resection. The median (interquartile range) overall adhesion score was 7 (5-8) in the open group and 0 (0-3) in the laparoscopic group (P < 0.001). A similar difference was found for the main incision score: 6 (4-6) versus 0 (0-0) (P < 0.001).

CONCLUSION

There may be a reduction in adhesion formation following laparoscopic compared with open colectomy, although the small sample size limits this conclusion.

A sprayable hydrogel adhesion barrier facilitates closure of defunctioning loop ileostomy: a randomized trial

PURPOSE

Closure of defunctioning loop ileostomy often is associated with division of complex peristomal adhesions through a parastomal incision with limited exposure. The goal was to determine whether sprayable hydrogel adhesion barrier (SprayGel) will reduce peristomal adhesions and facilitate closure of ileostomy.

METHODS

Patients undergoing closure of loop ileostomy were randomized to have hydrogel adhesion barrier sprayed around both limbs of ileostomy for 20 cm (SprayGel group, n = 19), or to control without adhesion barrier (control group, n = 21). Ileostomy was reversed at ten weeks after construction. Extent of peristomal adhesions was scored in blinded manner (each quadrant, range, 1-3: 3 = most severe; total, range, 4-12: 12 = most severe).

RESULTS

Use of adhesion barrier was associated with significant reduction in overall adhesion scores (mean, 6.11 vs. 9.67; P < 0.0005), four-quadrant adhesion scores (Quadrant A: 1.68 vs. 2.52, P = 0.002; Quadrant B: 1.42 vs. 2.33, P < 0.0005; Quadrant C: 1.42 vs. 2.24, P < 0.0005; Quadrant D: 1.58 vs. 2.48, P = 0.002), and proportion of patients with dense (scores > or = 8) adhesions (0.11 vs. 0.71; P < 0.0005). Time taken to mobilize (16.53 vs. 21.67 minutes; P = 0.008) and close ileostomy (35.37 vs. 41.90 minutes; P = 0.008) was significantly reduced. Postoperative complications were comparable.

CONCLUSIONS

A sprayable hydrogel adhesion barrier placed around the limbs of a defunctioning loop ileostomy reduced peristomal adhesions and might facilitate closure of ileostomy.

Peritoneal adhesions

An unsolved problem

Interferon-gamma is a therapeutic target molecule for prevention of postoperative adhesion formation

Intestinal adhesions are bands of fibrous tissue that connect the loops of the intestine to each other, to other abdominal organs or to the abdominal wall. Fibrous tissue formation is regulated by the balance between plasminogen activator inhibitor type 1 (PAI-1) and tissue-type plasminogen activator (tPA), which reciprocally regulate fibrin deposition. Several components of the inflammatory system, including cytokines, chemokines, cell adhesion molecules and neuropeptide substance P, have been reported to participate in adhesion formation. We have used cecal cauterization to develop a unique experimental mouse model of intestinal adhesion. Mice developed severe intestinal adhesion after this treatment. Adhesion development depended upon the interferon-gamma (IFN-gamma) and signal transducer and activator of transcription-1 (STAT1) system. Natural killer T (NKT) cell-deficient mice developed adhesion poorly, whereas they developed severe adhesion after reconstitution with NKT cells from wild-type mice, suggesting that NKT cell IFN-gamma production is indispensable for adhesion formation. This response does not depend on STAT4, STAT6, interleukin-12 (IL-12), IL-18, tumor necrosis factor-alpha, Toll-like receptor 4 or myeloid differentiation factor-88-mediated signals. Wild-type mice increased the ratio of PAI-1 to tPA after cecal cauterization, whereas Ifng(-/-) or Stat1(-/-) mice did not, suggesting that IFN-gamma has a crucial role in the differential regulation of PAI-1 and tPA. Additionally, hepatocyte growth factor, a potent mitogenic factor for hepatocytes, strongly inhibited intestinal adhesion by diminishing IFN-gamma production, providing a potential new way to prevent postoperative adhesions.

Practicalities and costs of adhesions

In spite of postoperative adhesions being common there appears to be a reluctance to use anti-adhesion products routinely. This article compares the incidence of adhesions with other conditions in order to identify the level of risk. The health economics surrounding adhesion-related disease are described. This combined information may be of help to convince health practitioners of the need to take a more active role in adhesion prevention. The SCAR project has identified the risk of adhesion-related disease. This is compared with published risks of other common clinical situations. An economic model first described by the author in 2002 has been revised with 2006 costs [1]. The SCAR data demonstrates a directly related risk of re-admission in certain groups of 9.4% over 5 years [2]. The frequency of including this fact in the consenting process is low (<15%) [3]. Legal precedent has identified a risk of >2% warrants inclusion in the consent process; failure to do so could be considered negligent [4]. Use of an anti-adhesion product with a cost of 130 euros with an efficacy of 25% in 1 year in the UK could save over 40 million euros over a 10-year period. Adhesion risk is frequent enough to include in consent. Failure to do this and avoidance of treatment, which may reduce adhesions will have major financial consequences on healthcare systems.

The magnitude of adhesion-related problems

Adhesions perhaps should be considered to be the most frequent complication of abdominopelvic surgery. The incidence is well documented but the burden to the cost of healthcare is not given the recognition it deserves. For any other disease or operation, with a recognized complication with such a high incidence, a prophylactic therapy or preventative strategy would be recommended if not mandatory. Adhesions occur in over 95% of all abdominal operations and can account for up to 6% of all readmissions. The problem affects all ages and exists for the life of the patient.

Adhesions and colorectal surgery - call for action

Mounting evidence highlights that adhesions are now the most frequent complication of abdominopelvic surgery, yet many surgeons are still not aware of the extent of the problem and its serious consequences. While many patients go through life without apparent problems, adhesions are the major cause of small bowel obstruction and a leading cause of infertility and chronic pelvic pain in women. Moreover, adhesions complicate future abdominal surgery with important associated morbidity and expense and a considerable risk of mortality. Studies have shown that despite advances in surgical techniques in recent years, the burden of adhesion-related complications has not changed. Adhesiolysis remains the main treatment even though adhesions reform in most patients. Recent developments in adhesion-reduction strategies and new anti-adhesion agents do, however, offer a realistic possibility of reducing the risk of adhesions forming and potentially improving the clinical outcomes for patients and reducing the associated onward burden to healthcare systems. This paper provides a synopsis of the impact and extent of the problem of adhesions with reference to the wider literature and also consideration of the key note papers presented in this special supplement to Colorectal Disease. It considers the evidence of the risk of adhesions in colorectal surgery and the opportunities and strategies for improvement. The paper acts as a 'call for action' to colorectal surgeons to make prevention of adhesions more of a priority and importantly to inform patients of the risks associated with adhesion-related complications during the consent process.