Laparoscopic adhesiolysis: consensus conference guidelines

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Individualization of the best approach for adhesive small bowel obstruction

BACKGROUND

Laparoscopic postoperatives outcomes in adhesiolysis are promising but conversion and morbidity remains high. The objective of our study was to determine preoperative factors to individualize and select the most appropriate approach for each patient.

METHODS

Patients ≥18 years old undergoing emergent surgery for adhesive small bowel obstruction and internal hernias were evaluated. Bivariate and multivariate analysis were performed to investigate factors related to conversion to open surgery and to the type of adhesions.

RESULTS

Of 333 patients, 224 were operated by laparotomy and 109 by laparoscopy (conversion rate: 40%). Previous abdominal wall mesh, type of adhesions, bowel lesion, need for intestinal resection and laparoscopic skills were statistically related to conversion. In the multivariate analysis, complex adhesions (OR 4.3, 95% CI 1.5-12.2; P = 0.006), the need for intestinal resection (OR 14.16, 95% CI 2.55-78.68; P = 0.002), and non-advanced laparoscopy surgeons (OR 4.31, 95% CI 1.56-11.94; P = 0.005) were independent factors for conversion to open surgery. ASA III-IV, previous surgeries, previous abdominal mesh and previous adhesiolysis were related to complex adhesions. Previous laparoscopic surgery and internal hernia or closed loop in computed tomography were associated with simple adhesions as a cause of the obstruction. In the multivariate, previous adhesiolysis (OR 4.76, 95% CI 1.23-18.3; P = 0.023) and the findings on computed tomography were significantly related with the type of adhesion.

CONCLUSION

Some preoperative factors allow to individualize the surgical approach in the adhesive small bowel obstruction improving surgical outcomes.

Progress in diagnosis and treatment of surgery-related adhesive small intestinal obstruction

Adhesive small bowel obstruction is a relatively common surgical acute abdomen, which is caused by various factors that result in the contents of the small bowel failing to pass smoothly. The clinical symptoms include abdominal pain, distension, nausea and vomiting, and defecation disorder. The chance of adhesive small bowel obstruction to develop in patients with a history of abdominal surgery is around 2.4%. This paper discusses the most recent developments in the conservative and surgical management of adhesive small bowel obstruction based on clinical manifestation, laboratory analysis, and imaging examination.

[Surgical approach for small bowel obstruction in the Russian Federation. National survey of surgeons]

OBJECTIVE

To study surgical approach for small bowel obstruction (SBO) regarding national and international guidelines.

MATERIAL AND METHODS

Considering literature data, national and international guidelines and clinical practice, we have formulated 15 questions regarding surgical approach for non-neoplastic SBO. Questions were sent by e-mail to the members of the Russian Society of Surgeons. Survey lasted 60 days. We used the program that provides the respondent with the possibility of visual control of survey results. Survey results were compared with national and international clinical guidelines, Russian- and English-language scientific publications. Restriction of the number of votes >1 and identification of respondents were not provided by the program. There was no reward for survey. A summary is provided on the main issues.

RESULTS

There were 557 respondents (3.0% of surgeons in the Russian Federation). We obtained 481-620 answers for each question.

CONCLUSION

This study is a valuable tool for primary assessment of current surgical practice for SBO in the Russian Federation. Study design did not imply conclusions on the optimal strategy based on opinions of majority of respondents. According to our survey, a significant number of respondents use the treatment strategy that differ from clinical guidelines. Their approach is based on their own clinical experience and local guidelines for the treatment of SBO. Less than half of the answers matched to national clinical guidelines, less than 10% - to the WSES guidelines. Despite the formal coincidence of some statements in national clinical guidelines and English-language recommendations, significant nonconformities require scientific discussion.

Adhesive small bowel obstruction: Single band or matted adhesions? A predictive model based on computed tomography scan

BACKGROUND

Preoperative identification of the cause of adhesive small bowel obstruction (ASBO) is crucial for decision making. Some computed tomography (CT) findings can be indicative of single adhesive bands or matted adhesions. Our aim was to build a predictive model based on CT data to discriminate ASBO due to single adhesive band or matted adhesions.

METHODS

A retrospective single center study was conducted, covering all consecutive patients with a preoperative CT scan, undergoing urgent surgery for ASBO between January 1, 2005, and December 31, 2017. Preoperative CT scans were blindly reviewed, and all the CT findings indicative of single adhesive band or matted adhesions described in literature were recorded. According to intraoperative findings, ASBOs were retrospectively classified into single band and matted ASBO. All observed CT findings were compared between the two groups. A predictive model based on logistic regression was developed, and its ability was quantified by discrimination and calibration. Internal cross-validation was conducted by bootstrap resampling.

RESULTS

A total of 116 patients were analyzed (males, 53.5%; median age, 68 years; single band ASBO in 65.5% of cases). The odds of single band ASBO were increased four times in presence of complete obstruction (odds ratios, 4.19; 95% confidence interval, 1.49-12.56) and seven times in presence of fat notch sign (odds ratios, 7.37; 95% confidence interval, 1.83-40.03). The predictive model combining all CT findings had an accuracy of 86% in single band ASBO prediction. Accuracy decreased to 79% in the internal validation. Sensitivity, specificity, and positive and negative predictive values were calculated at different cut-points of the predicted risk: using a 0.70 cut-point, the specificity is 80%, the sensitivity is 68%, and the positive and negative predictive values are 87% and 57%, respectively.

CONCLUSION

The proposed predictive model based on combination of specific CT findings may elucidate whether ASBO is caused by single bands or matted adhesions and, consequently, influence the clinical pathway.

LEVEL OF EVIDENCE

Prognostic study, level IV.

Adhesive Small Bowel Obstruction and the six w's: Who, How, Why, When, What, and Where to diagnose and operate?

BACKGROUND AND AIMS

Approximately 75% of patients admitted with small bowel obstruction have intra-abdominal adhesions as their cause (adhesive small bowel obstruction). Up to 70% of adhesive small bowel obstruction cases, in the absence of strangulation and bowel ischemia, can be successfully treated with conservative management. However, emerging evidence shows that surgery performed early during the first episode of adhesive small bowel obstruction is highly effective. The objective of this narrative review is to summarize the current evidence on adhesive small bowel obstruction management strategies.

MATERIALS AND METHODS

A review of the literature published over the last 20 years was performed to assess Who, hoW, Why, When, What, and Where diagnose and operate on patients with adhesive small bowel obstruction.

RESULTS

Adequate patient selection through physical examination and computed tomography is the key factor of the entire management strategy, as failure to detect patients with strangulated adhesive small bowel obstruction and bowel ischemia is associated with significant morbidity and mortality. The indication for surgical exploration is usually defined as a failure to pass contrast into the ascending colon within 8-24 h. However, operative management with early adhesiolysis, defined as operative intervention on either the calendar day of admission or the calendar day after admission, has recently shown to be associated with an overall long-term survival benefit compared to conservative management. Regarding the surgical technique, laparoscopy should be used only in selected patients with an anticipated single obstructing band, and there should be a low threshold for conversion to an open procedure in cases of high risk of bowel injuries.

CONCLUSION

Although most adhesive small bowel obstruction patients without suspicion of bowel strangulation or gangrene are currently managed nonoperatively, the long-term outcomes following this approach need to be analyzed in a more exhaustive way, as surgery performed early during the first episode of adhesive small bowel obstruction has shown to be highly effective, with a lower rate of recurrence.

Laparoscopic versus open approach for adhesive small bowel obstruction, a systematic review and meta-analysis of short term outcomes

BACKGROUND

Adhesive small bowel obstruction (ASBO) is one of the most frequent causes of emergency hospital admissions and surgical treatment. Current surgical treatment of ASBO consists of open adhesiolysis. With laparoscopic procedures rising, the question arises if laparoscopy for ASBO is safe and results in better patient outcomes. Although adhesiolysis was among the first surgical procedures to be approached laparoscopically, uncertainty remains about its potential advantages over open surgery. Therefore, we performed a systematic review and meta-analysis on the benefits and harms of laparoscopic surgery for ASBO.

METHODS

A systematic literature review was conducted for articles published up to May 2019. Two reviewers screened all articles and did the quality assessment. Consecutively a meta-analysis was performed. To reduce selection bias, only matched studies were used in our primary analyses. All other studies were used in a sensitivity analyses. All the outcomes were measured within the 30th postoperative day. Core outcome parameters were postoperative mortality, iatrogenic bowel perforations, length of postoperative stay [days], severe postoperative complications, and early readmissions. Secondary outcomes were operative time [min], missed iatrogenic bowel perforations, time to flatus [days], and early unplanned reoperations.

RESULTS

In our meta-analysis, 14 studies (participants = 37.007) were included: 1 randomized controlled trial, 2 matched studies, and 11 unmatched studies. Results of our primary analyses show no significant differences in core outcome parameters (postoperative mortality, iatrogenic bowel perforations, length of postoperative stay, severe postoperative complications, early readmissions). In sensitivity analyses, laparoscopic surgery favored open adhesiolysis in postoperative mortality (relative risk [RR], 0.36; 95% CI, 0.29-0.45), length of postoperative hospital stay (mean difference [MD], -4.19; 95% CI, -4.43 to -3.95), operative time (MD, -18.19; 95% CI, -20.98 to -15.40), time to flatus (MD, -0.98; 95% CI, -1.28 to -0.68), severe postoperative complications (RR, 0.51; 95% CI, 0.46-0.56) and early unplanned reoperations (RR, 0.82; 95% CI, 0.70-0.96).

CONCLUSION

Results of this systematic review indicate that laparoscopic surgery for ASBO is safe and feasible. Laparoscopic surgery is not associated with better or worse postoperative outcomes compared with open adhesiolysis. Future research should focus on the correct selection of those patients who are suitable for laparoscopic approach and may benefit from this approach.

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis, Level III.

Adhesive small bowel obstruction - an update

Small bowel obstruction (SBO) accounts for 12-16% of emergency surgical admissions and 20% of emergency surgical procedures. Even with the advent of laparoscopic surgery, intra-abdominal adhesions remain a significant cause of SBO, accounting for 65% of cases. History and physical examination are essential to identify signs of bowel ischemia as this indicates a need for urgent surgical exploration. Another critical aspect of evaluation includes establishing the underlying cause for obstruction and distinguishing between adhesive and non-adhesive etiologies as adhesive SBO (ASBO) can be managed non-operatively in 70-90% of patients. A patient with a history of abdominopelvic surgery along with one or more cardinal features of obstruction should be suspected to have ASBO until proven otherwise. Triad of severe pain, pain out of proportion to the clinical findings, and presence of an abdominal scar suggest possible closed-loop obstruction. Computed tomography has higher sensitivity and specificity compared to plain films and is recommended by the Bologna guidelines. Correcting fluid and electrolyte imbalance is an initial crucial step to mitigate severe hypovolemia. Patients should proceed with surgery if symptoms of bowel compromise are present, or if symptoms do not resolve or have worsened. Surgery is indicated in patients with ischemia, strangulation, perforation, peritonitis, or failure of non-operative treatment. With advances in minimal access technology and increasing experience, laparoscopic adhesiolysis is recommended. Mechanical adhesion barriers are an effective measure to prevent adhesion formation.

Laparoscopic versus open surgery for adhesional small bowel obstruction: a systematic review and meta-analysis of case-control studies

BACKGROUND

Small bowel obstruction (SBO) due to adhesions is a common acute surgical presentation. Laparoscopic adhesiolysis is being performed more frequently. However, the clear benefits of laparoscopic adhesiolysis (LA) compared with traditional open adhesiolysis (OA) remain uncertain. The aim of this study was to compare the outcomes of LA versus OA for SBO due to adhesions.

METHODS

A systemic literature review was conducted using PRISMA guidelines. A search was conducted using MEDLINE, EMBASE, PubMed and Cochrane Databases of all randomised controlled trials (RCT) and case-controlled studies (CCS) that compared LA with OA for SBO. Data were extracted using a standardised form and subsequently analysed.

RESULTS

There were no RCT. Data from 18 CCS on 38,927 patients (LA = 5,729 and OA = 33,389) were analysed. A meta-analysis showed that LA for SBO has decreased overall mortality (LA = 1.6% vs. OA = 4.9%, p < 0.001) and morbidity (LA = 11.2% vs. OA = 30.9%, p < 0.001). Similarly, the incidences of specific complications are significantly lower in the LA group. There are significantly lower reoperation rate (LA = 4.5% vs. OA = 6.5%, p = 0.017), shorter average operating time (LA = 89 min vs. OA = 104 min, p < 0.001) and a shorter length of stay (LOS) (LA = 6.7 days vs. OA = 11.6 days, p < 0.001) in the LA group. In the CCS, there is likely to be a selection bias favouring less complex adhesions in the LA group that may contribute to the better outcomes in this group.

CONCLUSIONS

Although there is a probable selection bias, these results suggest that LA for SBO in selected patients has a reduced mortality, morbidity, reoperation rate, average operating time and LOS compared with OA. LA should be considered in appropriately selected patients with acute SBO due to adhesions.

Small Bowel Obstruction

Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.

Modified Paul-Mikulicz jejunostomy in frail geriatric patients undergoing emergency small bowel resection

BACKGROUND

Proximal or extended bowel resections are sometimes necessary during emergency surgery of the small bowel and call for creating a high small bowel stomy as a part of damage control surgery. Secondary restoration of intestinal continuity in the frail geriatric patient, further weakened by subsequent severe malabsorption may be prohibitive.

METHODS

Six patients underwent emergency small bowel resection for proximal jejunal disease (83.3% high-grade adhesive SBO and 16.7% jejunal diverticulitis complicated with perforation). With the intention to avoid end jejunostomy and the need for repeat laparotomy for bowel continuity restoration we modified the classic Paul-Mikulicz jejunostomy.

RESULTS

The postoperative course was uneventful in four patients whose general condition improved considerably. At six-month follow-up, neither patients required parenteral nutrition.

CONCLUSIONS

This modified stoma can have the advantage of allowing a partial passage of the enteric contents, reducing the degree of malabsorption, and rendering jejunostomy reversal easy to perform later.

Early laparoscopic adhesiolysis for small bowel obstruction: retrospective study of main advantages

BACKGROUND

The problem of managing adhesional small bowel obstruction (ASBO) is still unsolved. A conservative medical attitude is privileged even if it is associated to a high rate of recurrences, while surgery is applied to cases showing no improvement after 48-72 h. Adhesiolysis via laparotomy has been the standard surgical management, but it causes other adhesions in a vicious circle. The aim of the study is to evaluate the advantages of early laparoscopic adhesiolysis as an alternative approach.

METHODS

From January 2010 to April 2017, 107 patients were admitted with a diagnosis of ASBO. Patients underwent medical treatment, early surgery, emergency surgery or delayed surgery after failure of medical treatment. A retrospective review and explorative statistical analysis were performed using graphical diagnostic plots, Mann-Whitney (MW) test, Kolmogorov-Smirnov (KS) test, exact binomial test, and χ ² test.

RESULTS

Medical treatment led to resolution in the 77.3% of cases, but patients exhibit much more recurrences than those in the surgical group (χ ² p < .001). They also show a longer fasting time (MW p = .027; KS p = .102), a doubled number of radiological exams (MW p < .001; KS p < .001), and more major complications than those in the early surgery group. Early surgery group is associated to shorter fasting time (MW p < .001; KS p < .001), much shorter hospital stay (MW p < .001; KS p = .002) and a smaller number of radiological exams (MW p = .005; KS p = .002) compared with delayed surgery group. The laparoscopic group shows significantly earlier regain of intestinal transit (MW p < .001; KS p = .002), shorter fasting time (MW p = .002; KS p = .008), reduced number of radiological exams (MW p = .003; KS p = .014), reduced hospital stay (MW p < .001; KS p = .005), and no more complications than the open surgery group.

CONCLUSIONS

Early laparoscopic surgery can be proposed as an effective alternative treatment for ASBO.

A retrospective study of laparoscopic surgery for small bowel obstruction

Background

Open laparotomy is widely accepted as the standard surgical treatment for small bowel obstruction (SBO). However, laparoscopic surgery has recently become a treatment option. There is no consensus on the appropriate settings for the laparoscopic treatment of SBO. The purpose of this study is to evaluate the outcomes of laparoscopic surgery for SBO.

Patients and methods

From January 2012 to May 2016, 48 consecutive patients underwent surgical treatment for SBO in our department. We retrospectively reviewed these cases and compared the features and the outcomes between laparoscopic and open surgery.

Results

Thirty-four and 14 patients underwent open surgery and laparoscopic surgery, respectively. Four of the laparoscopic cases (28.6%) were converted to open surgery. Laparoscopic surgery tended to be associated with a shorter operative time than open surgery (p = 0.066). The first postoperative oral intake was significantly earlier in patients who underwent laparoscopic surgery (p = 0.044). The duration of hospitalization after surgery and the rates of postoperative complications did not differ to a statistically significant extent. Laparoscopic treatment was accomplished in 7 out of 8 cases (87.5%) with SBO due to band occlusion.

Conclusion

Laparoscopic surgery for SBO is less invasive than open surgery and is equally feasible in selected patients. SBO due to band occlusion may be a preferable indication for laparoscopic surgery. In order to confirm the safety of laparoscopic treatment, and to clarify the appropriate settings for laparoscopic surgery for SBO, it will be necessary to perform further studies in a larger population and with a long follow-up period.

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Surgical treatment for small bowel obstruction in 48 patients were retrospectively reviewed.

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Laparoscopic surgery was performed in 14 patients, and 4 cases were converted to open surgery.

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Laparoscopic surgery is less invasive than open surgery and is equally feasible in selected patients.

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Band occlusion may be a preferable indication to laparoscopic surgery.

Will laparoscopic lysis of adhesions become the standard of care? Evaluating trends and outcomes in laparoscopic management of small-bowel obstruction using the American College of Surgeons National Surgical Quality Improvement Project Database

Small-bowel obstruction (SBO) is a common disorder and constitutes a significant healthcare burden. Laparoscopic lysis of adhesions (LLOA) for SBO is predicted to decrease complications, shorten hospital stay, and cut healthcare costs compared with the open lysis of adhesions (OLOA); however, large comparison studies are lacking. We evaluated the nationwide adoption of LLOA and compared outcomes with OLOA. We retrospectively analyzed data from 9920 OLOA and 3269 LLOA cases from 2005 to 2013 using the American College of Surgeons prospective National Surgical Quality Improvement Program data set. Annual trends were evaluated using linear regression. Surgery outcomes were compared using two-sample t tests or Mann-Whitney tests. Post-surgical complications were compared using multivariable logistic regression adjusting for comorbidities. The proportion of SBO cases treated by LLOA increased nationwide by 1.6 percent per year (R ² 0.87), from 17.2 % in 2006 to 28.7 % in 2013. Patients undergoing OLOA had longer operations (66 vs 60 min, P < 0.001), longer hospital stay (8.9 vs 4.2 days, P < 0.001), and higher post-surgical complication rates (adjusted odds ratio 2.73 95 % CI 2.36-3.15, P < 0.001) when compared to LLOA. Despite the lack of prospective randomized trials comparing LLOA to OLOA, we found progressive nationwide adoption of LLOA for SBO treatment. Our large retrospective analysis demonstrated clinical benefit and reduced resource utilization for LLOA.

A systematic review comparing laparoscopic vs open adhesiolysis in patients with adhesional small bowel obstruction

BACKGROUND AND OBJECTIVE

To evaluate whether surgical outcomes differ between laparoscopic vs open approach for adhesiolysis in patients presenting with adhesional small bowel obstruction (ASBO).

DATA SOURCE

A systematic review of literature on published studies reporting the surgical outcomes after laparoscopic vs open adhesiolysis for ASBO was undertaken using the principles of meta-analysis.

RESULTS

Fourteen comparative studies on 38,057 patients, evaluating the surgical outcomes in patients undergoing laparoscopic vs open adhesiolysis for ASBO were analyzed. Laparoscopic adhesiolysis resulted in the reduced risk of morbidity (P < .00001), mortality (P < .0001), and surgical infections (P = .003). In addition, the risk of respiratory complications, cardiac complications, bowel resection, and venous thromboembolism was lower with shorter hospitalization in laparoscopic adhesiolysis group. However, statistical equivalence was seen in variables of duration of operation and iatrogenic enterotomies.

CONCLUSIONS

Laparoscopic adhesiolysis for ASBO seems to have clinically proven advantage over open approach.

Adhesive small bowel adhesions obstruction: Evolutions in diagnosis, management and prevention

Intra-abdominal adhesions following abdominal surgery represent a major unsolved problem. They are the first cause of small bowel obstruction. Diagnosis is based on clinical evaluation, water-soluble contrast follow-through and computed tomography scan. For patients presenting no signs of strangulation, peritonitis or severe intestinal impairment there is good evidence to support non-operative management. Open surgery is the preferred method for the surgical treatment of adhesive small bowel obstruction, in case of suspected strangulation or after failed conservative management, but laparoscopy is gaining widespread acceptance especially in selected group of patients. "Good" surgical technique and anti-adhesive barriers are the main current concepts of adhesion prevention. We discuss current knowledge in modern diagnosis and evolving strategies for management and prevention that are leading to stratified care for patients.

Laparoscopic versus open surgical management of small bowel obstruction: an analysis of clinical outcomes

BACKGROUND

Laparotomy is the standard surgical approach for treatment of small bowel obstruction (SBO). Laparoscopic management could be beneficial in terms of less complications and shorter hospital stay. As the minimal invasive approach is gaining more acceptances in the treatment of SBO, there is an increased need of studies to analyze outcomes. The aim of the present study was to compare the short-term clinical outcomes of laparoscopy versus laparotomy in the surgical management of non-bariatric, non-malignant SBO.

METHODS

A retrospective analysis of patients treated for SBO during 2010-2015 was made by a comprehensive search of medical records. A matched-pair review was performed on patients managed surgically for non-bariatric, non-malignant SBO at Danderyd University Hospital, Stockholm, Sweden. Completed laparoscopic surgeries were matched against patients treated with open surgery.

RESULTS

Laparoscopy for SBO was initiated in 71 patients. Conversion to open surgery was performed in 42 %. Results from the matched-pair analysis showed that post-operative length of stay was reduced by 60 % (P < 0.001) in the laparoscopic cohort. Additionally, less major complications were reported and duration of surgery was reduced by 50 % (P < 0.001).

CONCLUSIONS

Laparoscopic management is a safe and feasible alternative to laparotomy. Hospital length of stay was significantly shorter and morbidity rate acceptable.

Clinical Treatment and Analysis of Laparoscopic Enterolysis Surgery

This work aims to explore the application value and clinical efficacy of laparoscopic enterolysis surgery for the treatment of adhesive intestinal obstruction. A total of 126 inpatient cases of intestinal adhesion were selected. In order to observe the effects and complications of surgery, the patients were randomly assigned into laparoscopic and laparotomy groups, with 63 cases in each group. The operative time, blood loss, postoperative ambulation time, exhaustion time, postoperative analgesia number of patients, and hospital days of the patients in the laparoscopic group were compared with those in the control group, and the differences were all statistically significant (p < 0.05). In the laparoscopy group, two patients experienced rupture of the small intestine during the surgery, but recovered well after endoscopic suture repair, although there was one case of postoperative pulmonary infection. The difference was statistically significant in the laparotomy group of patients, with one case of intestinal fistula, two cases of surgical wound infection, one case of incisional hernia, three cases of postoperative pulmonary infection, and one case of urinary tract infection. Compared with laparotomy, laparoscopic enterolysis surgery has shorter operative time, less blood loss, faster postoperative recovery, and fewer complications.

Laparoscopic Surgery in Luminal Gastrointestinal Emergencies-a Review of Current Status

Laparoscopy has already established itself as the preferred surgical approach in a variety of elective surgical conditions. Along with its usual advantages of less tissue trauma and faster recovery, its diagnostic as well as therapeutic role is making it an attractive option in emergency surgery. In this paper, we have reviewed the current status of laparoscopic surgery in luminal gastrointestinal emergencies. Relevant papers were selected using Medline database from 2007 to the present. These were reviewed, and outcomes were stated under the headings of appendicitis, perforated peptic ulcer, colorectal emergencies and small bowel obstruction. The laparoscopic intervention was found to be of clear benefit in most of the patients with appendicitis. Its role, however, is not absolutely clear in managing perforated peptic ulcers. Laparoscopic lavage and drainage have been recommended in diverticular perforation with limited contamination. Small case series and studies have shown benefits of laparoscopic surgery in iatrogenic colonic perforations, colonic obstruction, emergency colectomy and small bowel obstruction. Laparoscopic surgery can be recommended in appendicitis and low-risk cases of perforated peptic ulcers. Its definitive role in other conditions needs more evidence. The surgeon's experience and careful patient selection are very important to improve the outcome.

Laparoscopic versus open surgical management of adhesive small bowel obstruction: a comparison of outcomes

BACKGROUND

Laparoscopic management of adhesive small bowel obstruction (SBO) has become an established technique within the domain of acute care surgery. As minimally invasive management of SBO becomes more widely accepted, there is increased need for reporting of outcomes.

OBJECTIVE

To compare outcomes of laparoscopic versus open surgery for adhesive SBO.

METHODS

Patients undergoing surgery for adhesive SBO at our institution between 2005 and 2013 were eligible for inclusion. The primary outcome was overall complication rate, while secondary outcomes included operative time, gastrointestinal (GI) function, and postoperative length of stay (LOS). Univariable analysis compared laparoscopic (including conversions) and open groups with regard to patient baseline and perioperative characteristics as well as outcomes of interest. Multivariable analysis was performed comparing the endpoint of overall complications between groups. Sensitivity analysis excluding patients who underwent bowel resection was performed to assess effect on outcomes. Factors associated with laparoscopic success, as well as impact of conversion to open on postoperative outcomes, are reported.

RESULTS

A cohort of 269 patients with adhesive SBO was identified: 186 patients (69.1%) underwent open surgery, 83 (30.9%) were managed laparoscopically. Within the laparoscopy group, 32 (38.6%) underwent conversion to open. Operative time was similar between groups (P = 0.506), while laparoscopy was associated with quicker recovery of GI function indicated by removal of nasogastric tube (P = 0.031) and passage of flatus (P = 0.005). Postoperative LOS was shorter (5 vs. 7 days, P = 0.031) with laparoscopy. The overall complication rate was significantly lower in the laparoscopic group (27.7 vs. 43.6%, P = 0.014), with an adjusted odds ratio (OR) for overall complications of 0.37 (P = 0.002). Following exclusion of bowel resections, secondary outcomes continued to favor laparoscopy, while reduction in overall complications trended toward significance, OR 0.47 (P = 0.050).

CONCLUSION

Laparoscopic surgical management of adhesive SBO was associated quicker GI recovery, shorter LOS, and reduced overall complications compared to open surgery.

Laparoscopic versus open adhesiolysis for small bowel obstruction - a multicenter, prospective, randomized, controlled trial

Background

Laparoscopic adhesiolysis is emerging as an alternative for open surgery in adhesive small bowel obstruction. Retrospective studies suggest that laparoscopic approach shortens hospital stay and reduces complications in these patients. However, no prospective, randomized, controlled trials comparing laparoscopy to open surgery have been published.

Methods/Design

This is a multicenter, prospective, open label, randomized, controlled trial comparing laparoscopic adhesiolysis to open surgery in patients with computed-tomography diagnosed adhesive small bowel obstruction that is not resolving with conservative management. The primary study endpoint is the length of postoperative hospital stay in days.

Sample size was estimated based on preliminary retrospective cohort, which suggested that 102 patients would provide 80% power to detect a difference of 2.5 days in the length of postoperative hospital stay with significance level of 0.05. Secondary endpoints include passage of stool, commencement of enteral nutrition, 30-day mortality, complications, postoperative pain, and the length of sick leave. Tertiary endpoints consist of the rate of ventral hernia and the recurrence of small bowel obstruction during long-term follow-up. Long-term follow-up by letter or telephone interview will take place at 1, 5, and 10 years.

Discussion

To the best of our knowledge, this trial is the first one aiming to provide level Ib evidence to assess the use of laparoscopy in the treatment of adhesive small bowel obstruction.

Trial registration

ClinicalTrials.gov identifier: NCT01867528. Date of registration May 26th 2013.

Conservative treatment of adhesive small bowel obstruction in children: a systematic review

OBJECTIVE

To assess the effectiveness of conservative treatment for adhesive small bowel obstruction (ASBO) in children.

DESIGN

Systematic review of studies involved children with ASBO who received initial conservative/non-operative treatment.

SETTING

The search was performed in April 2013 using PubMed (see online supplementary file 1), current contents, and the Cochrane database.

PARTICIPANTS

Children with ASBO.

INTERVENTIONS

Conservative treatment included nasogastric decompression, parenteral fluids and correction of electrolyte and fluid imbalance.

PRIMARY OUTCOME

Treatment success.

SECONDARY OUTCOMES

Length of hospital stay and the time to first feeding after hospital admission.

RESULTS

7 studies (six retrospective, one prospective), involving 8-109 patients (age: 1 month to 16 years) treated conservatively, were included in the review. The nature of conservative treatment was generally consistent between studies (nasogastric decompression, parenteral fluids and correction of electrolyte and fluid imbalance), although patients in one study also received Gastrografin. The rate of conservative treatment success ranged from 16% to 75% among the five studies, but one trial showed 0% successful rate. The hospital length of stay ranged from 3 to 6.5 days for conservative treatment (vs 10.2-13 days for operative treatment). The time to first feeding ranged from 31 to 84 h for conservative treatment.

CONCLUSIONS

In conclusion, in the majority of cases, conservative treatment is an effective means of managing ASBO in children.

Emergency laparoscopic ileocecal resection for Crohn's acute obstruction

This report suggests that laparoscopic ileocecal resection for acute ileal obstruction secondary to Crohn's disease is a prudent and feasible management option.

Introduction:

Emergency surgery for Crohn's disease (CD) is a rare entity, and its indications are scant in the published literature. Emergency laparoscopy for small bowel obstruction has gained wide dissemination with the spread of advanced laparoscopic skills within surgical practice. Therefore, incidental terminal ileitis after exploration might be a more-common finding in the near future, and further studies are needed to better ascertain proper surgical treatment.

Case Description:

We report on a case of acute obstruction caused by undiagnosed terminal ileitis associated with CD.

Discussion and Conclusion:

The patient underwent explorative laparoscopy and subsequent video-assisted ileocecal resection with an optimal outcome.

[A preliminary experience in the laparoscopic approach to bowel obstruction]

BACKGROUND

The laparoscopic approach to bowel obstruction is still controversial.

OBJECTIVE

To evaluate our initial results in the laparoscopic treatment of bowel obstruction.

MATERIAL AND METHODS

A retrospective study on patients diagnosed with bowel obstruction that underwent laparoscopic surgery within the time frame of January 2008 to June 30, 2012. The variables employed were: age, sex, occlusion etiology, previous surgeries, clinical progression, pneumoperitoneum creation, use of an auxiliary incision, anesthesia duration, conversion rate, postoperative hospital stay, time needed to tolerate liquids, and complications.

RESULTS

Twenty-six patients, 18 women (69.2%) and 8 men (30.8%), with a mean age of 64.35 years (range: 21-92 years) were analyzed. The most frequent obstruction etiology was secondary to adhesions and presented in 12 cases. Nine patients (34.6%) underwent a completely laparoscopic approach and laparoscopy was complemented by an auxiliary incision in another 9 patients (34.6%), resulting in 18 cases (69.2%) of successful laparoscopic approach. Eight patients (30.8%) required conversion to open surgery. The mean anesthesia duration was 95min (range: 55-165min), mean postoperative hospital stay was 6 days (range: 3-72 days), and the mean amount of time needed to tolerate liquids was 3 days (range: 1-10 days). The patients that underwent complete laparoscopic approach presented with shorter hospital stay, they were able to ingest liquids earlier, and they presented with a lower number of postoperative complications; this latter variable was the only one that was statistically significant.

CONCLUSIONS

The initial results of our experience were good, although more patients are needed in order to standardize and extend the use of this technique.

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

Background

In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy.

Recommendations

In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay.

NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended.

Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery.

Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.

Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.

Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.

Single-port laparoscopic management of adhesive small bowel obstruction

Laparoscopic adhesiolysis has been the focus of much recent attention; however, the role of single-port laparoscopic surgery for adhesive small bowel obstruction remains unclear. We report our experience of performing single-port laparoscopic surgery for adhesive small bowel obstruction through a retrospective review of 15 consecutive patients who underwent single-port laparoscopic surgery for single adhesive small bowel obstruction between 2010 and 2012. We analyzed data on patient demographics, operating time, conversion, and surgical morbidity. Surgery was completed successfully without conversion to laparotomy or the need for additional intraoperative ports in 14 patients, but the remaining patient had peritoneal dissemination from colon cancer. The median operative time was 49 (25-148) min, and the estimated blood loss was 19 (2-182) ml. There were no major postoperative complications. We conclude that single-port laparoscopic surgery is a technically feasible approach for selected patients with adhesive small bowel obstruction when preoperative imaging identifies a single adhesive obstruction.

‘Let's Just Wait One More Day': Impact of Timing on Surgical Outcome in the Treatment of Adhesion-Related Small Bowel Obstruction

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

Enhancement of a small bowel obstruction model using the gastrografin® challenge test

BACKGROUND

Based on a previous published data on small bowel obstruction (SBO), a management model for predicting the need for exploration has been adopted in our institution. In our model, patients presenting with three criteria-the history of obstipation, the presence of mesenteric edema, and the lack of small bowel fecalization on computed tomography (CT)-undergo exploration. Patients with two or less features were managed nonoperatively. An alternative tool for predicting need for operative intervention is Gastrografin (GG) challenge test.

HYPOTHESIS

We hypothesized that the GG challenge test, when used in combination with our prior model, will decrease the rate of explorations in patients not meeting the criteria for immediate operation.

METHODS

An approval from IRB was obtained to review patients admitted with a diagnosis of SBO from November 2010 to September 2011. All patients presenting with signs of ischemia, patients with all three model criteria defined previously, and those who had an abdominal operation within 6 weeks of diagnosis were excluded. All patients had an abdominal/pelvic CT and GG challenge at the time of diagnosis. Patients were compared to historic controls managed without the GG challenge (from July to December 2009). Successful GG challenge was defined as the presence of contrast in the colon after a follow-up film or a bowel movement. Data were presented as medians or percentages; significance was considered at p < 0.05.

RESULTS

One hundred and twenty-five patients with a diagnosis of small bowel obstruction were identified wherein 47 % were males. Fifty-three received a GG challenge (study), and 72 did not have a GG challenge (historic). There was no difference in age (70 vs 65 years), history of prior SBO (51 vs 49 %), history of diabetes mellitus (21 vs 18 %), history of malignancy (32 vs 39 %), or cardiac disease (30 vs 39 %). Both groups had similar number of previous abdominal operations (two vs two). The presence of mesenteric edema (68 vs 75 %), the lack of small bowel fecalization (47 vs 46 %), and a history of obstipation (25 vs 24 %) were similar in both groups. Patients in the study group had a lesser rate of abdominal exploration (25 vs 42 %, p = 0.05) and fewer complications (13 vs 31 %, p = 0.02) compared to the historic control group. There was equivalent incidence of ischemic bowel (4 vs 7 %), duration of hospital stay (4 vs 7 days), duration from admission to operation (2 vs 3 days), and mortality (8 vs 6 %); 44 patients had a successful GG challenge with nine failures. There was a greater rate of exploration in patients with a failed challenge compared to those with a successful challenge (89 vs 11 %, p < 0.01).

CONCLUSION

The use of the GG challenge enhanced the SBO prediction model by decreasing the need for exploration in patients not meeting the criteria for immediate operation. Patients who failed the GG challenge test were much more likely to undergo an exploration.