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A POPULATION LEVEL ANALYSIS OF ADHESIVE SMALL BOWEL OBSTRUCTION AFTER ABDOMINAL SURGERY: SIGNIFICANT AND SUSTAINED ADVANTAGE OF A LAPAROSCOPIC APPROACH
Brooks Udelsman*1, Elan Witkowski1, Mark A. Talamini2, Keith D. Lillemoe1, Chang David1
1Surgery, Massachusetts General Hospital, Boston, MA; 2Surgery, Stony Brook Medicine, Stony Brook, NY

Background: Post-operative adhesive small bowel obstructions (aSBOs) are a significant contributor to long-term post-operative morbidity. This complication represents an important public health concern and is a major factor when considering long-term costs of surgical intervention. Previous studies have been limited to single center trials or have a single organ system focus with follow up of only a few years.

Methods: Retrospective cohort study using the Public Discharge Data file (1995-2010) of the California Office of Statewide Health Planning and Development, which has 100% capture across all hospitals California. We identified cohorts who underwent six common procedures: roux-en-Y gastric bypass (RYGB), cholecystectomy, partial colectomy, Cesarean section, appendectomy, and hysterectomy. We excluded patients with prior abdominal surgery, ventral hernias, inflammatory bowel disease, history of pelvic inflammatory disease, and metastatic cancer. We also excluded patients who developed an obstruction within 7 days of initial surgery. The primary outcome of aSBO was identified via diagnosis codes (ICD-9 560.81 and 560.9). Patients were censored for death, a second abdominal surgery, or the end of the study period. Clinical, patient, and hospital characteristics were assessed using Kaplan-Meir method and Cox regression analysis adjusting for demographics, comorbidities, and operative characteristics.

Results: Among 2,723,019 surgical procedures performed, there were 18,890 episodes of first time aSBO requiring inpatient admission. Median follow up time was 6.3 years (IQR 3.0 to 10.6 years). The incident rate of aSBO ranged from 0.07 episodes per 1000-person year for Cesarean section to 8.34 episodes per 1000-person years for an open partial colectomy (Figure 1). Overall, 25.3% of patients required an operative intervention for their aSBO with the highest rate of operative intervention occurring in patients with prior RYGB (41.2%) and the lowest rate of operative intervention occurring in patients with prior cholecystectomy (16.8%). For every procedure, the risk of aSBO was increased with an open approach (Figure 2). The protective effect of a laparoscopic approach was greatest in the first 2 years. Patient factors including female gender and African American race were associated with increased risk of aSBO. Operative factors associated with increased risk were an open approach and in the case of partial colectomy involvement of the left or sigmoid colon.

Conclusions: Surgical approach is a modifiable risk factor across multiple abdominal surgeries and associated with a significantly and sustained decrease in rate of aSBO formation, while non-modifiable independent risk factors include African American race and female gender.
Figure 1: Cumulative incidence (a) and rate (b) of first-time adhesive small bowel obstruction (aSBO) for partial colectomy (pColectomy), roux-en-y gastric bypass (RYGB), hysterectomy, cholecystectomy, appendectomy, and Cesarean section (C-Section). Ninety-five percent confidence intervals (95% CI) are depicted by the shaded region around the line. While cumulative incidence continues to increase over time, the highest rate of aSBO formation is within the first 2 years after initial surgery.

Figure 1: Cumulative incidence (a) and rate (b) of first-time adhesive small bowel obstruction (aSBO) for partial colectomy (pColectomy), roux-en-y gastric bypass (RYGB), hysterectomy, cholecystectomy, appendectomy, and Cesarean section (C-Section). Ninety-five percent confidence intervals (95% CI) are depicted by the shaded region around the line. While cumulative incidence continues to increase over time, the highest rate of aSBO formation is within the first 2 years after initial surgery.

Figure 2: Cumulative incidence and rate of first-time adhesive small bowel obstruction (aSBO) after open or laparoscopic partial colectomy, roux-en-y gastric bypass (RYGB), hysterectomy, cholecystectomy, or appendectomy. Ninety-five percent confidence intervals (95% CI) are depicted by the shaded region around the line. Cumulative incidence of aSBO is greater after an open approach in all procedures and the protective effect of a laparoscopic approach is greatest in the first 2 years after initial surgery.


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