Laparoscopic Adhesiolysis in Small Bowel Obstruction Reduces 30-Day Complications and Length of Stay

Kristin N Kelly, MD, James C Iannuzzi, MD, Aaron S Rickles, MD, Veerabhadram Garimella, MD, MRCS, John RT Monson, MD, FRCS, Fergal J Fleming, MD, FRCS

University of Rochester Surgical Health Outcomes & Research Enterprise, Department of Surgery

INTRODUCTION:
Small bowel obstruction (SBO) requiring adhesiolysis is a frequent and costly problem in the United States accounting for approximately 118 hospitalizations per 100,000 patients in 2005 and expenditures exceeding 1.4 billion dollars1. There is limited high quality evidence available regarding the most effective and safest surgical management strategies. This study examines the differences in 30-day surgical outcomes between patients treated with laparoscopy for SBO and their counterparts undergoing open procedures.

METHODS AND PROCEDURES:
Patients with a discharge diagnosis of adhesive SBO (ICD-9 560.81) were selected from the ACS National Surgical Quality Improvement Program (NSQIP) database from 2005-2010. Cases were classified as either laparoscopic or open adhesiolysis groups, with or without small bowel resection using Common Procedural Terminology (CPT) codes. Chi-square and Student’s T-test were used to compare patient and surgical characteristics with 30-day outcomes including: major complications, incisional complications, and mortality. Factors with a p<0.1 were included in the multivariate logistic regression for each outcome. A propensity score analysis for probability of being a laparoscopic case was performed, but did not significantly affect results. A two sided p-value <0.05 was considered significant.

RESULTS:
Of the 9,619 SBO included in the analysis, 14.9% adhesiolysis procedures were performed laparoscopically. Patients undergoing laparoscopic procedures had shorter mean operative times (77.2 vs. 94.2 minutes, p<0.001) and decreased post-operative length of stay (4.7 vs. 9.9 days, p<0.001). After controlling for comorbidities and surgical factors, patients having open adhesiolysis were more likely to develop major complications (OR=1.57, CI: 1.29-1.90, p<0.001) and incisional complications (OR=4.62, CI: 3.10-6.90, p<0.001). The 30-day mortality was 4.7% in the open group versus 1.3% in the laparoscopic group (OR=2.08, CI: 1.26-3.44, p=0.004). In patients requiring small bowel resection in addition to adhesiolysis the laparoscopic rate fell to 4.3% of cases. There were more major complications (OR=2.63, CI: 1.46-4.73, p=0.001) and incisional complications (OR=2.29, CI: 1.18-4.45, p=0.014) in the resection group for open compared to laparoscopic procedures. Mean operative times in the resection plus adhesiolysis group did not significantly differ between open and laparoscopic cases (127.7 vs. 116 minutes, p=0.119); however, post-operative length of stay remained significantly shorter in the laparoscopic cases (11.6 vs. 7.8 days, p<0.001).

CONCLUSIONS:
Laparoscopic adhesiolysis requires a specific skill set and experience and may not be appropriate in all patients. Notwithstanding this, the laparoscopic approach demonstrates a benefit in length of stay, mean operative time, and 30-day morbidity and mortality even after controlling for preoperative patient characteristics. Given these findings in over 9,000 cases and consistent rates of SBO requiring surgical intervention in the United States, increasing the use of laparoscopy could be a feasible way of improving patient outcomes and decreasing attendant costs.

1) Sikirica et al. The inpatient burden of abdominal and gynecological adhesiolysis in the US. BMC Surgery 2011, 11:13.

Session: Podium Presentation

Program Number: S097