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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 112-114

Incidence of adhesive small bowel obstruction and outcome of management


Department of General Surgery, Rashid Hospital, Dubai, United Arab Emirates

Date of Submission16-Aug-2020
Date of Decision09-Jun-2021
Date of Acceptance10-Jun-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Maahroo Makhdoom
Department of General Surgery, Rashid Hospital, Oud Mehta Road, PO Box: 4545, Dubai
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_69_20

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  Abstract 


Background: Small bowel obstruction (SBO) is a common surgical condition that leads to emergency admission. Adhesions are the single most common cause for SBO, accounting for 60% of cases. The occurrence of adhesive SBO (ASBO) is higher following specific surgeries including colorectal, high gynaecological and paediatric surgeries. Initially, all patients are treated conservatively, but in case they fail to improve, surgical management is considered. Aim & Objectives: The objective of the study is to assess the number of patients admitted at Rashid Hospital with ASBO and the outcomes of their management. Materials and Methods: A retrospective study was conducted on patients who were admitted with ASBO from April 2017 until December 2019. A total of number of 85 patients who met the inclusion criteria were enrolled in the study. Those with underlying inflammatory bowel disease, abdominal tuberculosis and small bowel tumours were excluded. The outcomes of non-operative management (NOM) in terms of success rate, length of hospital stay and surgical intervention were assessed. Result: A total of 303 records were reviewed, of which 85 met the inclusion criteria (50 males and 35 females). The most common type of previous abdominal surgeries includes lower gastrointestinal (38.8%) and gynaecological surgeries (12.9%). Seventy-eight patients who underwent NOM had a success rate of 77.6% (n = 59) with a mean length of stay (LOS) of 3.5 days. Seventeen patients (22.4%) needed surgical intervention after a mean of 3.5 days. These patients were found to have intra-abdominal bands in 52.9% of the cases (P = 0.191). During the time period set for the study, the recurrence rate of patients who had successful NOM versus those who needed surgical intervention was 12% and 35.3%, respectively (P = 0.061). Sixty per cent of these recurrent cases were treated non-operatively on the second admission to the hospital whereas 40% required surgical intervention. Conclusion: NOM for ASBO has a shorter LOS and a lower recurrence rate as compared to those who required surgical management.

Keywords: Adhesiolysis, adhesion, adhesive small bowel obstruction, non-operative management


How to cite this article:
Makhdoom M, Makhdoom S, Kaiyasah H, Al Ozaibi L. Incidence of adhesive small bowel obstruction and outcome of management. Hamdan Med J 2021;14:112-4

How to cite this URL:
Makhdoom M, Makhdoom S, Kaiyasah H, Al Ozaibi L. Incidence of adhesive small bowel obstruction and outcome of management. Hamdan Med J [serial online] 2021 [cited 2021 Dec 7];14:112-4. Available from: http://www.hamdanjournal.org/text.asp?2021/14/3/112/327427




  Introduction Top


Small bowel obstruction (SBO) is a common surgical emergency that leads to admission. Adhesions are the most common cause for SBO, accounting for 60% of cases.[1],[2] Non-adhesive aetiologies include incarcerated hernias, obstructive lesions (malignant and benign) and a number of infrequent causes for bowel obstruction such as bezoars, inflammatory bowel disease, tuberculosis and volvulus.[3]

Adhesive SBO (ASBO) is high following specific surgeries including colorectal, gynaecological and paediatric surgeries. One in ten patients develops at least one episode of SBO within 3 years after a colectomy.[3] Initially, if the patient is clinically and biochemically stable, a trial of conservative management is initiated with nasogastric decompression, intravenous fluids and correction of electrolyte disturbances. In case patients deteriorate during this time or fail to improve with conservative treatment, surgical management is considered. Surgery can be either performed as diagnostic laparoscopic surgery or exploratory laparotomy and proceed accordingly. Laparoscopic surgery may be converted to open surgery depending on the intraoperative findings and surgical expertise. Studies found that the rate of recurrence of SBO was lesser and occurred after longer period of time after surgical intervention. This study will be assessing the number of patients who were admitted at Rashid Hospital General Surgery Department with the diagnosis of ASBO, the number of patients treated conservatively and surgically will be compared.


  Materials and Methods Top


A retrospective study was conducted with content analysis (retrospective cohort study) at Rashid Hospital, United Arab Emirates. Ethical approval was obtained from Dubai Scientific Research Ethics Committee, Dubai Health Authority (reference number MERD-RRP-20-04-05). All patients from April 2017 until December 2019 who were admitted as ASBO were included in the study. A database query was performed to identify patients who were admitted with SBO and past history of abdominal surgeries. Patients with post-operative ileus or other possible diagnoses of bowel obstruction were excluded such as inflammatory bowel disease, abdominal tuberculosis, strangulating hernias and underlying tumours.

Only complete medical records were used in the study to ensure that all necessary information was available and accurate. Patients' gender and age were included as demographic data. The index ASBO was defined as the first experienced episode of SBO at our facility.

Details of past abdominal surgeries were documented including the type of surgery (whether it was an upper gastrointestinal, lower gastrointestinal, gynaecological surgery, hernia repair (excluding open inguinal hernia repair), trauma surgery or surgery for another reason (including VP shunt insertion, mesenteric cyst excision, cytoreductive surgery or laparotomy for unknown cause). The time interval between the last surgery and the index SBO, any previous episodes of ASBO and the management were also documented.

The number of patients who were started on non-operative management (NOM) initially versus those who were taken for operative management (OM) on admission was noted. Those who underwent NOM were assessed regarding the success rate and length of stay (LOS). The patients with failed NOM were also assessed with regard to the type of surgery they underwent and the intraoperative findings. Of particular interest was to note if there was an intra-abdominal fibrous band that could have possibly predisposed to failure of this treatment approach.

Recurrence of symptoms requiring readmission was also checked to assess if there was a link between the type of management and recurrence.

Data were collected through the electric medical record SALAMA system and collated into an Excel spreadsheet. SPSS software [Statistical Package for the social sciences ,IBM.] was used for data analysis. Mean and standard deviation were used to summarise numerical variables, median and range were used to summarise skewed numerical variables and count and percentage were used to summarise categorical variables. The Pearson's Chi-squared test was used to compare categorical data between the successful and failed NOM groups, and in some analyses, Mann–Whitney test was used. Statistical significance was defined as P < 0.05.


  Results Top


A total of 303 records were reviewed, of which 85 met the inclusion criteria (50 males and 35 females). The most common age group of patients was between 20 and 40 years, accounting for 41.2% of the population [Table 1].
Table 1: Age distribution of the sample size

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The most common type of previous abdominal surgeries were lower gastrointestinal (38.8%) and gynaecological surgeries (12.9%). The less common surgeries were laparotomies for trauma (7.1%), upper gastrointestinal surgeries (5.9%), hernia (2.4%) and other procedures (5.9%) including VP shunt insertion, mesenteric cyst excision and cytoreductive surgery for metastatic testicular cancer.

It was noted that patients who had undergone only one prior abdominal surgery represented 63.5% of the population in comparison to 36.5% for those who had more than one surgery.

Seventy-eight patients who underwent NOM had a success rate of 77.6% (n = 59) with a mean LOS of 3.5 days. Seventeen patients (22.4%) needed surgical intervention after a mean of 3.5 days. These patients were found to have intra-abdominal bands in 52.9% of the cases (P = 0.191).

The patients who were treated with surgical management upon admission had a total LOS of 12.4 days.

In total, 24 patients required surgery. Most of the patients underwent an exploratory laparotomy (95.3%) whereas the rest underwent laparoscopic surgery. In total, 12 patients underwent adhesiolysis and 12 underwent small bowel resection. The type of surgery for failed NOM and OM is mentioned in [Table 2] and [Table 3].
Table 2: Comparison of number of bowel resection versus adhesiolysis between failed non-operative management and operative management groups

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Table 3: Comparison of open versus laparoscopic surgery between failed non-operative management and operative management groups

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Patients who had failed NOM were intraoperatively found to have intra-abdominal bands in 52.9% of the cases (P = 0.191) whereas those with OM were found to have bands in 85.7% of the cases.

During the time period set for the study, the recurrence rate of patients who had successful NOM versus those who needed surgical intervention was 12% and 35.3%, respectively (P = 0.061).

The recurrence rate in patients who were treated non-operatively was 12%, as compared to 35.3% in patients who required surgical intervention in the failed NOM group (P = 0.061).

Sixty per cent of these recurrent cases were treated non-operatively on the second admission to the hospital whereas 40% required surgical intervention.


  Discussion Top


ASBO has been deemed to be a lifelong complication after abdominal surgery. In our study, it was found that patients with previous lower gastrointestinal and gynaecological surgeries were the most common procedure preceding the development of ASBO (38.8% and 12.9%, respectively). This goes in concordance with William et al. who reported colorectal and gynaecological surgeries contributing to 4% and 28% of the population.[4]

'The sun should never rise or set on a SBO' was a precept that was considered as a criterion for managing cases of SBO in the past. This has substantially changed over the last two decades with the advent of NOM as the initial approach of management. Köstenbauer et al. mentioned a success rate of 80% in patients treated with partial SBO whereas Seror et al. had a 73% success.[5],[8] Our success rate of 77.6% goes well with these reports.

Patients with successful NOM had a mean LOS of 3.5 days versus 17.9 days for those with failed NOM. Williams et al. had a similar trend whereas Jeffrey et al. reported patients having a longer stay at the hospital stay of 8 and 20 days for NOM and failed NOM, respectively.[4],[6] Our study also goes hand in hand with Köstenbauer et al. who recommended a maximum duration of NOM of 72 h.[5]

Computed tomography (CT) abdomen with oral water-soluble contrast has been shown to have both diagnostic and therapeutic values in management of ASBO and reduces the need for surgery by 20%.[4] In our study, only four patients on NOM underwent abdominal CT scan with oral contrast during their stay. Majority of patients had a CT abdomen with IV contrast only at the time of admission. Out of the patients who received the oral contrast, one patient had a scan on admission and symptomatically improved within the next 24 h. The other three patients had the imaging after a mean of 5.3 days that showed resolution of obstruction.

After failure of NOM, 47% of the patients underwent bowel resection when taken for surgery, whereas 57% of the OM group had bowel resection. This was comparable to Thornblade et al. where it was found that expectant management had a lower rate of bowel resection compared to those taken for direct surgery with a percentage of 10% versus 29%.[7] These values, however, were much lower than the ones resulted in our study.

Interestingly, it was found that intra-abdominal bands were present in 85.7% of the patients who went for direct surgery versus 52.9% in those with failed NOM.

Open surgery was the preferred method of surgical treatment for strangulating ASBO as well as those with failed NOM. The rate of open surgery was 83% in all patients taken for surgery.

There were no mortalities noted in either arm of managements, however, this could be attributed to the low sample size of the study.


  Conclusion Top


NOM for ASBO has a shorter LOS and a lower recurrence rate as compared to those who required surgical management. However, more studies with a larger sample size and a longer duration of assessment might be needed to clearly assess the trend of recurrence rates.

Ethical clearance

Ethical approval was obtained from Dubai Scientific Research Ethics Committee, Dubai Health Authority (reference number MERD-RRP-20-04-05).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ten Broek RP, Issa Y, van Santbrink EJ, Bouvy ND, Kruitwagen RF, Jeekel J, et al. Burden of adhesions in abdominal and pelvic surgery: Systematic review and met-analysis. BMJ 2013;347:f5588.  Back to cited text no. 1
    
2.
Catena F, Ansaloni L, Di Saverio S, Pinna AD, World Society of Emergency Surgery. P.O.P.A. study: Prevention of postoperative abdominal adhesions by icodextrin 4% solution after laparotomy for adhesive small bowel obstruction. A prospective randomized controlled trial. J Gastrointest Surg 2012;16:382-8.  Back to cited text no. 2
    
3.
Ten Broek RP, Krielen P, Di Saverio S, Coccolini F, Biffl WL, Ansaloni L, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg 2018;13:24.  Back to cited text no. 3
    
4.
Williams SB, Greenspon J, Young HA, Orkin BA. Small bowel obstruction: Conservative vs. surgical management. Dis Colon Rectum 2005;48:1140-6.  Back to cited text no. 4
    
5.
Köstenbauer J, Truskett PG. Current management of adhesive small bowel obstruction. ANZ J Surg 2018;88:1117-22.  Back to cited text no. 5
    
6.
Jeffrey L, T H Cogbill, W H Randel T S, P J S, RN. Long-term outcome after hospitalization.  Back to cited text no. 6
    
7.
Thornblade LW, Verdial FC, Bartek MA, Flum DR, Davidson GH. The safety of expectant management for adhesive small bowel obstruction: A systematic review. J Gastrointest Surg 2019;23:846-59.  Back to cited text no. 7
    
8.
Seror D, Feigin E, Szold A, et al. How conservatively can postoperative small bowel obstruction be treated? The American journal of surgery. 1993;165(1):121-126. [https://dx.doi.org/10.1016/S0002-9610(05)80414-3. doi: 10.1016/S0002-9610(05)80414-3].  Back to cited text no. 8
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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