|Year : 2020 | Volume
| Issue : 2 | Page : 205-207
Post-operative adhesive intestinal obstruction
TK Ravidas, KC Soman, Sreekanth S Kumar
Department of General Surgery, Government Medical College, Kozhikode, Kerala, India
|Date of Submission||03-Aug-2020|
|Date of Decision||13-Aug-2020|
|Date of Acceptance||14-Oct-2020|
|Date of Web Publication||07-Nov-2020|
Dr. T K Ravidas
Thottungal House, Yakkara Road, Palakkad - 678 014, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: Post-operative adhesions are the most important cause of small-bowel obstruction. This article aims to analyse the clinical manifestations, causes and management of patients diagnosed with post-operative adhesive intestinal obstruction. Methodology: The study was conducted in 91 patients aged >12 with characteristics of intestinal obstruction who were having a previous history of abdominal surgery. Scores were given for each clinical parameter. From the data collected various clinical manifestations, previous surgeries and intraoperative findings and their management were analysed. Pearson Chi-Square test and Fisher's exact test were used to examine the data in SPSS software. Results: Open appendicectomy was the most common previous surgery. The average interval between the onset of symptoms after surgery was 36 months. More number of recurrent adhesive small-bowel obstruction were associated with colorectal surgeries. Majority of the surgical intervention was made after 48 h of presentation and conservative treatment. Majority of the operated patients underwent adhesiolysis. There was a significant relationship between clinical features such as vomiting constipation, tachycardia, hypotension and operative management. Conclusion: Early surgery is advised for patients with clinical features of strangulation and conservative management for uncomplicated cases and surgical intervention if the progression of symptoms occurs. No effective prophylaxis could be found.
Keywords: Adhesive intestinal obstruction, clinical features, laparotomy
|How to cite this article:|
Ravidas T K, Soman K C, Kumar SS. Post-operative adhesive intestinal obstruction. Kerala Surg J 2020;26:205-7
| Introduction|| |
Peritoneal adhesions can be defined as abnormal fibrous bands between organs or tissues in the abdominal cavity that are normally separated. It may be acquired or congenital. The most common cause of attained peritoneal adhesion is abdominopelvic surgery. A less common cause is intraperitoneal infection or abdominal trauma.
| Methodology|| |
The article aims to analyse the clinical manifestations, causes and management of patients diagnosed with post-operative adhesive intestinal obstruction in surgical wards of Calicut Medical College from May 2018 to May 2019. In this descriptive study, patients above 12 years presenting with features of intestinal obstruction with a history of previous laparotomy/laparoscopy whose operative details were included in the study. Patients unfit for anaesthesia (ASA 4), those unwilling for study and patients refusing surgery were excluded from the study. Details recorded included: Demographic data, comorbidities, details of previous abdominal operations, admission vital marks, laboratory outcomes, marks of abdominal X-ray and marks of USG or computed tomography (CT). Scores were given for each clinical parameter. Conservative treatment comprised gastrointestinal decompression, intravenous fluid resuscitation, antibiotics usage and correction of electrolyte levels. The operation was performed if conservative treatment was judged to have failed, based on no amendment of obstruction marks or on the outgrowth of marks of intestinal strangulation. From the data collected various clinical manifestations, previous surgeries causing it and the percentage of various surgeries contributing for adhesive intestinal obstruction were analysed. Among the cases managed surgically intraoperative findings and the procedure done are also noted. Sample size was calculated as 92 (n = 4pq/d × d = 4 × 48 × 52/10.4 × 10.4 (p = Incidence of post-operative intestinal obstruction = 48%; q = 100 − p d = 20% of q) = 92.
| Results|| |
Of the 92 patients, one had obstructive transverse colon growth, unrelated to the previous surgery he underwent; hence, he was excluded from the study. Of the rest, 68 (74.7%) were males and 23 (25.3%) females. The age ranged from 15 to 75 years. Majority of the patients (61) belonged to the age group between 20 and 40 (67%), followed by 23 patients (25.3%) between 20 and 40 years, 4 (4.4%) <20 years and 3 (3.3%) >60 years, respectively.
The primary surgery varied among patients. Twenty-six patients (28.6%) presented with post-operative intestinal obstruction had appendicectomy as primary surgery. Fifteen (16.5%) had gynaecological surgeries such as caesarean section, hysterectomy and post-partum sterilisation. Fourteen (15.4%) had colorectal surgeries, 11 (12.1%) had upper GI surgeries, 10 (11%) had laparotomy for blunt trauma abdomen and 13 (14.3%) had other surgeries such as hepatobiliary, pancreatic, urological and ventriculoperitoneal shunt surgeries and 2 (2.2%) had laparoscopic surgeries [Figure 1].
Out of the 91 patients, 12 (13.2%) had previous surgery for adhesive obstruction. Among the operated patients, 4 (33.3%) had previous colorectal surgeries, followed by 3 (25%) gynaecological surgeries and 2 (16.6%) appendicectomies, One (8.3%) had blunt trauma and two (16.6%) had an adhesive obstruction. Majority of patients – 62 (68.1%) had a history of one previous surgery, 26 (28.6%) had two and three patients (3.3%) had >2 surgeries in the past, maximum being 4. The minimum time interval was 3 weeks and the maximum was 22 years with an average time interval of 36 months. Forty-five (49.5%) patients presented within 1–4 years of previous surgery, followed by 30 (32.9%) patients <1 year and 16 patients (17.6%) >4 years.
All the 91 patients had abdominal distension. Eighty-six (94.5%) had abdominal pain at time of presentation, 60 (65.9%) tachycardia, 43 (47.3%) vomiting, 33 (36.3%) constipation, 8 (8.8%) fever and 7 (7.7%) hypotension [Figure 2].
All the patients were subjected to plain X-ray of the abdomen and all showed dilated bowel loops. Fifty-one patients (56%) showed multiple air-fluid levels (>3). The most common electrolyte abnormality noted was hypokalemia (<3.5 meq/dl). Sixty-four patients (70.3%) were managed conservatively; 27 (29.7%) underwent operative management. Of the 86 patients with pain, 27 (31.4%) were operated and 59 (68.6%) managed conservatively. Twenty-three out of 43 patients (53.5%) with vomiting had surgical intervention, while the rest 20 (46.5%) were managed conservatively. Of 33 patients with constipation, 24 (72.7%) were operated upon, whereas 9 (27.3%) had surgery. Twenty-five (41.7%) patients out of 60 patients with tachycardia had surgery and 35 (58.3%) were managed conservatively. Six (85.7%) of the seven patients with hypotension had surgery and 1 (14.3%) was managed conservatively. Of the eight patients with fever, 4 (50%) were managed surgically and the rest conservatively.
Among the patients managed operatively statistically significant relationship was noted for clinical features such as vomiting, constipation, tachycardia and hypotension (P < 0.005) whereas abdominal pain and fever were not statistically significant (P = 0.135 and P = 0.187, respectively).
About 51.8% of patients were operated after 48 h of admission, 25.9% within 24–48 h and 22.2% within 24 h of presentation. All laparotomies done were through midline vertical incision. Among operatively managed, 25 patients had the site of adhesion at small bowel and two patients had large bowel and small bowel adherent to each other producing obstruction. Six patients with features of strangulation were operated without delay. Remainder of them were observed for the development of worsening of symptoms and seven operated within 24–48 h, 14 after 48 h.
Twelve out of 27 (44.4%) patients underwent adhesiolysis. Eight (29.6%) patients were found to have bands causing an obstruction which were released and 7 (25.9%) patients underwent resection anastomosis as the obstructed area did not show any signs of viability. Among the patients who underwent laparotomy two patients expired due to post-operative respiratory and cardiovascular complications.
| Discussion|| |
Adhesive small-bowel obstruction (ASBO) is a common surgical emergency, having high morbidity and even mortality. The adhesions making such bowel obstructions are typically the footprints of former abdominal surgical procedures. Numerous efforts have been taken to prevent post-operative adhesions but till now no methods have been found to be completely effective. Initially, patients are treated conservatively provided there are no signs of strangulation. The World Society of Emergency Surgery has brought out recommendations regarding SBO management in 2013, stating that surgical treatment should be projected whenever medical treatment failed to achieve SBO resolution 72 h following introduction. There was a male preponderance in our study (about 74.7%). The age ranged from 15 to 75 years, the majority belonging to 20–40 years (67%). Majority of the patients had underwent open surgeries indicating the effect of peritoneal handling in post-operative adhesion formation.
According to the previous studies majority of the patients presented with adhesive intestinal obstruction had appendicectomy as the primary surgery ,, which was comparable with our study. The reason for this association may be due to the high incidence of appendicectomy among emergency procedure in my institution and high chances of peritoneal contamination with abscess formation and increased bowel handling during surgery due to mass formation. Long-term incidence of adhesion-related to post-operative obstruction has been measured in two prospective, randomised studies to compare laparoscopy versus. laparotomy for colorectal surgery. These studies showed a statistically significant difference in the post-operative obstruction rate: 5.1% versus 6.5% in Schölin et al. study, 2.5% versus 3.1% in Taylor et al. study. The highest post-operative obstruction rate was observed in the group of patients that required conversion from laparoscopy to laparotomy (6%). The operation rate for the patients varied between 15% and 40% according to previous studies , in our study, it was 29.7%. The study also showed 22% of patients had a previous history of the surgery for ASBO as compared with our study it amounted to 13.2%. The average time interval between previous surgery and intestinal obstruction was 36 months. According to Miller and Winfield, it varied between 1 month and 38 years. In the study done by Carcia et al. the mean duration was found to be 5.5 years. In the present study, the duration varied with a minimum of 3 weeks and maximum of 22 years According to Fevang et al., number of previous surgeries in patients presenting with ASBO were 1 in 77%, 2 in 17% and 3 or more in 6% against 68.1%, 28.6% and 3.3% respectively in the present study.
We found a significant relationship between clinical features such as vomiting, constipation, tachycardia, hypotension and operative management. However, this cannot be used as a diagnostic tool for predicting strangulation. Majority of the surgical intervention was made after 48 h of presentation and conservative treatment. However, others feel that surgical intervention should not be delayed as there are more chances of bowel gangrene in delaying surgery. The decision of surgical intervention should be made between 12 and 24 h if there is a progression of symptoms. None of the patients in the present study had procedures such as Nobles application, Child Philippe trans mesenteric plication or Backer tube intubation. It is done when there is recurrent and massive adhesion.
| Conclusion|| |
Males predominated in our study. Most of the patients were between 20 and 40 years. Open appendicectomy was found to be the most common previous surgery that resulted in adhesive obstruction. The average interval between the onset of symptoms after surgery was 36 months. More number of recurrent ASBO were associated with colorectal surgeries. The management of post-operative adhesive intestinal obstruction in our hospital includes early surgery for patients with evidence of strangulation such as severe abdominal pain tachycardia and hypotension. Conservative management was given for uncomplicated cases. The decision for operative management was made after frequent examination for the progression of symptoms. Majority of surgical intervention was made after 48 h of presentation and conservative treatment. Majority of the operated patients underwent adhesiolysis. There was a significant relation between clinical features such vomiting, constipation, tachycardia, hypotension and operative management.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]