ACS NSQIP Analysis: Moridity and Mortality with Laparoscopic and Open Lysis of Adhesions for Bowel Obstruction.

Subhash Reddy, MD, Jonathan Grotts, MA, David Thoman, MD

Santa Barbara Cottage Hospital

Background
Adhesions account for 50-70% of all Small bowel obstructions in adults. Historically after conservative management fails a laparotomy is performed to enable lysis of adhesions (LOA). There are a growing number of small series demonstrating decreased morbidity and shorter stay with laparoscopic LOA. We sought to identify risk factors for adverse postoperative events after open or laparoscopic LOA by querying a large national database.

Methods
Under the data use agreement for the American College of Surgeons National Surgical Quality Improvement (NSQIP) Program Public Use File, and with the institutional review board approval, we reviewed perioperative variables of patients who underwent LOA with principal diagnosis of bowel obstruction from 2006 to 2010. Patients who underwent any additional procedure apart from LOA were excluded. The primary endpoint was mortality and secondary endpoints included post-operative adverse events. A multivariate model was used to control for pre-operative morbidity, age and BMI. Odds ratio (OR), Chi square, logistic regression were performed using SPSS 2011

Results
Of 3499 patients who had LOA, 768 (21.9%) were done laparoscopically. Overall, patients who had laparotomy were older and had higher ASA scores. There was no difference in total duration of surgery (P=0.12). Postoperative complications were more common in the laparotomy group and length of stay was significantly longer (9 day vs 4 days). Demographics and univariate analysis of postoperative adverse events are listed in the table with odds ratio.

Using multivariate regression analysis: perioperative variables like age > 70, respiratory, sepsis, renal and neurological comorbities (P<0.05) were independently associated with mortality and respiratory adverse events. For wound infection, BMI > 30 and diabetes were independently associated (P<0.05). Preoperative sepsis (OR 2) and steroid (OR 3) usage increased the risk of blood transfusions (P<0.05). Laparoscopic LOA had protective effect on all postoperative adverse events (P<0.05) with maximum benefit in regards to blood transfusions.

DEMOGRAPHICS & POSTOPERATIVE ADVERSE EVENTS

Variables

Open

n=2731(%)

Laparoscopy

n=768(%)

p value
Mean Age 63 years 58 years p<0.001
Male 1098(40.2) 248(32.3) p<0.001
Mean BMI 26 27.3 p<0.001
ASA 3,4,5 1717(63.4) 359(46.7) p<0.001
Previois Surgery within 30 days 111(41.1) 35(4.6) p=0.6
Total Duration of Surgery (mean) 60 minutes 60 minutes p=0.43
Total Length of Stay (mean) 9 days 4 days p<0.001
Steroids 116(4.2) 20(2.6) P<0.03
Postoperative Wound Infection 180(6.6) 16(2.1)

OR 3.3

(P<0.001)

Postoperative respiratory adverse events 194(7.1) 20(2.6)

OR 2.9

p(<0.001)

Postoperative cardiac adverse events 16(0.6) 4(0.5)

OR 1.1

(p=0.8)

Urinary Tract Infection 137(5) 13(1.7)

OR 3.0

(p<0.001)

Unplanned Return to OR 137(5) 13(1.7)

OR 1.0

(p=0.9)

Bleeding Requiring Transfusions 48(1.8) 2(0.3)

OR 6.8

(p<0.001)

Mortality 109(4) 9(1.2)

OR 3.3

(p<0.001)

Conclusion
Based on a large national database, lysis of adhesions performed laparoscopically results in significantly fewer postoperative complications and a much shorter hospital stay. However, the patients approached by laparotomy tended to be older with more comorbidities.


Session: Poster Presentation

Program Number: P629

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