Background: Colorectal surgery (CRS) leads to high rates of access-related complications. Adhesive small bowel obstruction (SBO) is reported as high as 35% with large clinical impact and financial burden. In this study we evaluated the cumulative incidence of adhesive SBO in a cohort of patients after CRS. We also assessed the role of laparoscopy as adhesion prevention strategy.
Methods: Data on patients undergoing elective or emergency CRS (either open or laparoscopic) were prospectively entered in a database. Adhesive SBO episodes requiring admission or reintervention were recorded. The diagnosis of SBO was defined by a combination of clinical criteria and imaging. Time interval of SBO, surgery type and setting, readmission length and findings at reintervention were recorded. Patients undergoing CRS for inflammatory bowel disease, patients with peritoneal carcinosis, or patients with SBO secondary to local or peritoneal recurrence during the follow-up were excluded. Patients who underwent other abdominal surgery during the follow-up were also excluded. Data were analysed using Mann-Whitney U test and chi-square test. The Kaplan Meier method was used to calculate the cumulative probability of developing SBO.
Results: from 1/03 to 10/07, 426 patients satisfied our criteria and underwent elective (48.6%) or emergency (51.4%) colorectal surgery (73.7% open and 26.3% laparoscopic). Mean follow-up was 28 months. Eleven (2.6%) patients experienced 14 SBO episodes and 8 (1.9%) required surgery. There was a large variation in the first readmission interval, 54% occurred within 3 months, 38.5% between 3 and 12 months and 14.3% after 1 year. At first admission 54.5% of patients underwent surgery. Seven patients required adhesiolysis and 1 patient needed resection for small bowel ischaemia. The risk of readmission for SBO was higher during the first postoperative year and the cumulative risk steadily increased every year thereafter. The risk of reoperation was related to the number of readmissions for SBO, doubling at the second readmission and reaching 100% after the third. Mean length of stay was 8 and 15 days respectively for non-operative and operative treatment. SBO risk was significantly higher after pelvic surgery/extensive resections compared to minor procedures (5.2% vs 2,6%; p< 0.03), after open compared to laparoscopic (3.2% vs 0.9%; p< 0.001) but similar after emergency surgery compared to elective (NS).
Conclusions: Colorectal surgery results in significant ongoing risk of SBO depending from the colorectal procedure. The number of readmissions for SBO predicts the need of surgery. Laparoscopy seems to minimize the risk of adhesive SBO.