James P Byrne, BScEng, MD, Fady Saleh, MD, MPH, FRCSC, Luciano Ambrosini, MD, Carolina Jimenez, MD, Joshua Gnanasegaram, Fayez Quereshy, MD, MBA, FRCSC, Timothy D Jackson, MD, MPH, FRCSC, Allan Okrainec, MDCM, MHPE, FACS, FRCSC. Division of General Surgery, University Health Network, University of Toronto.
As the laparoscopic management of acute small bowel obstruction (SBO) grows as a tool in the armamentarium of the acute care surgeon, it is critical that outcomes are tracked to aid surgeons in making evidence-based decisions with regards to management of their patients. The purpose of this study was to review outcomes in patients with SBO treated laparoscopically compared to those treated by open surgery.
We performed a retrospective review of all patients managed surgically for small bowel obstruction at our institution from 2009 to 2012. Data abstracted included pre-operative patient characteristics and investigations. Outcomes collected included details of postoperative recovery, length of stay (LOS), morbidity and mortality. The laparoscopic group included all cases started as such, regardless of conversion. Continuous variables were compared using Student’s t-test, while categorical variables with the Chi-square test. Univariate and multivariate analysis provided a comparison of the incidence of complications between both groups, while multivariable logistical regression was performed to assess predictors of adverse outcome.
A total of 246 patients were managed surgically for acute small bowel obstruction during this period. 83 patients were treated with laparoscopy, while 163 had conventional open surgery. The most common etiology found at surgery was adhesive (63%). Mean operative time was not significantly different between laparoscopic and open surgery groups (143.0 vs. 151.0 minutes, p=0.362). There was however a significant reduction in time to recovery of bowel function in the laparoscopic group as indicated by passage of flatus (3.0 vs. 4.0 days, p=0.017), as was there in median length of stay (5 vs. 8 days, p<0.001). Overall complication rate was significantly lower in those treated with laparoscopic surgery (30.1% vs. 45.4%, p=0.021), with associated reduction in the odds of an adverse event through multivariable logistical regression (OR 0.50, 95%CI 0.28 – 0.91, p=0.024).
Treatment of patients with small bowel obstruction by an initial laparoscopic approach is safe, associated with quicker recovery, reduced length of stay, and a reduction in adverse outcome as compared to conventional open management. Further research is needed to understand predictors of successful laparoscopic completion.
| Complication | Open, n (%) | Laparoscopic, n (%) | OR (95% CI) | P-value |
|---|---|---|---|---|
| Surgical site infection | 39 (23.9) | 14 (16.9) | 0.65 (0.30-1.32) | 0.203 |
| Early reoperation | 9 (5.5) | 4 (4.8) | 0.87 (0.19-3.22) | 0.816 |
| Death | 16 (9.8) | 3 (3.6) | 0.34 (0.06-1.26) | 0.085 |
| Major complications | 41 (25.2) | 12 (14.5) | 0.50 (0.23-1.06) | 0.054 |
| Any Complication | 74 (45.4) | 25 (30.1) | 0.52 (0.28-0.95) | 0.021 |
| Variable | Odds Ratio | 95% CI | P-value |
|---|---|---|---|
| Laparoscopic vs. Open Approach | 0.50 | 0.28-0.91 | 0.024 |
| Age | 1.03 | 1.01-1.05 | 0.003 |
| ASA* | 1.69 | 0.57-5.02 | 0.348 |
| Male | 1.34 | 0.77-2.32 | 0.298 |
| Previous abdominal surgery | 0.86 | 0.45-1.63 | 0.650 |
| Hypertension | 0.85 | 0.45-1.57 | 0.595 |
| Diabetes mellitus | 1.10 | 0.52-2.29 | 0.806 |
| Cardiac disease | 1.43 | 0.76-2.68 | 0.267 |
*ASA 3-5 compared to 1-2